Provider Demographics
NPI:1588725519
Name:KELLEHER, INEZ M (MD)
Entity type:Individual
Prefix:DR
First Name:INEZ
Middle Name:M
Last Name:KELLEHER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1397 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2419
Mailing Address - Country:US
Mailing Address - Phone:228-575-1945
Mailing Address - Fax:228-575-1964
Practice Address - Street 1:1340 BROAD AVE
Practice Address - Street 2:STE 450
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503
Practice Address - Country:US
Practice Address - Phone:228-867-5012
Practice Address - Fax:228-867-5262
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16601207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07555001Medicaid
F45059Medicare UPIN
MS200000491Medicare ID - Type Unspecified