Provider Demographics
NPI:1538406574
Name:MARY C KANNANKERIL MD.,PA
Entity type:Organization
Organization Name:MARY C KANNANKERIL MD.,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:C
Authorized Official - Last Name:KANNANKERIL
Authorized Official - Suffix:
Authorized Official - Credentials:MDPA
Authorized Official - Phone:973-276-0041
Mailing Address - Street 1:170 CHANGEBRIDGE RD
Mailing Address - Street 2:SUITE B 3-4
Mailing Address - City:MONTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07045-9115
Mailing Address - Country:US
Mailing Address - Phone:973-276-0041
Mailing Address - Fax:973-628-1935
Practice Address - Street 1:170 CHANGEBRIDGE RD
Practice Address - Street 2:SUITE B 3-4
Practice Address - City:MONTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07045-9115
Practice Address - Country:US
Practice Address - Phone:973-276-0041
Practice Address - Fax:973-628-1935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-10
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty