Basic Information
| Provider Information | |||||||||
| NPI: | 1841240462 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLEHER | ||||||||
| FirstName: | MARGARET | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4200 N ARMENIA AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138774811 | ||||||||
| FaxNumber: | 8138728978 | ||||||||
| Practice Location | |||||||||
| Address1: | 6110 DR MARTIN LUTHER KING JR ST N | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337031142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278213600 | ||||||||
| FaxNumber: | 7278213611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 07/09/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | ME 63128 | FL | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 306242 | 01 | AVMED | OTHER | 1368171 | 01 | COVENTRY | OTHER | 18974 | 01 | FL | FL BLUE | OTHER | 7416827 | 01 | AETNA | OTHER |