Basic Information
| Provider Information | |||||||||
| NPI: | 1366580730 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLNER | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | H. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 GUSTAVE L. LEVY PLACE, | ||||||||
| Address2: | BOX 1230 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126598838 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 GUSTAVE L. LEVY PLACE, | ||||||||
| Address2: | BOX 1230 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739720037 | ||||||||
| FaxNumber: | 9739729355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 08/31/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 25MA07375600 | NJ | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0805X | 25MA07375600 | NJ | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 5651409 | 05 | NJ | MEDICAID |