Healthcare Provider Details

I. General information

NPI: 1992766588
Provider Name (Legal Business Name): KENNETH SHERRARD KELLEHER JR. M.D., FACS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NATIONAL NAVAL MEDICAL CENTER 8901 WISCONSIN AVE
BETHESDA MD
20889-0001
US

IV. Provider business mailing address

1311 ROOSEVELT ST
ALEXANDRIA VA
22302-3129
US

V. Phone/Fax

Practice location:
  • Phone: 301-295-4472
  • Fax: 301-295-0959
Mailing address:
  • Phone: 703-671-1386
  • Fax: 301-295-0959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101032853
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: