Provider Demographics
NPI:1750396503
Name:KELLEHER, RAYMOND J III (MD PHD)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:J
Last Name:KELLEHER
Suffix:III
Gender:M
Credentials:MD PHD
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Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-726-1728
Mailing Address - Fax:617-726-4101
Practice Address - Street 1:15 PARKMAN STREET
Practice Address - Street 2:NEUROLOGY ASSOCIATES WAC 835
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3117
Practice Address - Country:US
Practice Address - Phone:617-726-1728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2012-08-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA1529432084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA750080OtherTUFTS HEALTH PLAN
MA3191915Medicaid
MAJ19901OtherBCBS MA
MA750080OtherTUFTS HEALTH PLAN
MA3191915Medicaid