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General NPI Number Information
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NPI Number | 1598966244
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Entity Type | Organization
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Legal Business Name | PAUL MITCHELL KELLEHER
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Dates
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Enumeration Date | 05/30/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 4434 AMBOY RD
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City | STATEN ISLAND
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State | NY
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Zip | 10312-3866
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Country | US
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Telephone | 718-227-7015
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Fax |
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Provider Business Mailing Address
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Address Line | 49 W RAYBURN RD
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City | MILLINGTON
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State | NJ
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Zip | 07946-1502
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Country | US
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Telephone | 908-542-1792
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. PAUL MITCHELL KELLEHER
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Credential | D.O.
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Telephone | 717-818-3167
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081S0010X
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Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 206597
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License Number State | NY
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