Healthcare Provider Details

I. General information

NPI: 1588725519
Provider Name (Legal Business Name): INEZ M KELLEHER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 BROAD AVE STE 450
GULFPORT MS
39503
US

IV. Provider business mailing address

1397 BROAD AVE
GULFPORT MS
39501-2419
US

V. Phone/Fax

Practice location:
  • Phone: 228-867-5012
  • Fax: 228-867-5262
Mailing address:
  • Phone: 228-575-1945
  • Fax: 228-575-1964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number16601
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: