Provider Demographics
NPI:1992766588
Name:KELLEHER, KENNETH SHERRARD JR (MD, FACS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:SHERRARD
Last Name:KELLEHER
Suffix:JR
Gender:M
Credentials:MD, FACS
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Mailing Address - Street 1:1311 ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-3129
Mailing Address - Country:US
Mailing Address - Phone:703-671-1386
Mailing Address - Fax:301-295-0959
Practice Address - Street 1:NATIONAL NAVAL MEDICAL CENTER
Practice Address - Street 2:8901 WISCONSIN AVE
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-0001
Practice Address - Country:US
Practice Address - Phone:301-295-4472
Practice Address - Fax:301-295-0959
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
VA0101032853208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC36600Medicare UPIN