Provider Demographics
NPI:1366580730
Name:KELLNER, CHARLES H (MD)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:H
Last Name:KELLNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUSTAVE L. LEVY PLACE,
Mailing Address - Street 2:BOX 1230
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6574
Mailing Address - Country:US
Mailing Address - Phone:212-659-8838
Mailing Address - Fax:
Practice Address - Street 1:1 GUSTAVE L. LEVY PLACE,
Practice Address - Street 2:BOX 1230
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6574
Practice Address - Country:US
Practice Address - Phone:973-972-0037
Practice Address - Fax:973-972-9355
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA073756002084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5651409Medicaid
NJ065087Medicare ID - Type Unspecified
NJ5651409Medicaid