Healthcare Provider Details

I. General information

NPI: 1205452356
Provider Name (Legal Business Name): KELLEN HALEY QUIGG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2020
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

1447 BICENTENNIAL PKWY
ANN ARBOR MI
48108-7918
US

V. Phone/Fax

Practice location:
  • Phone: 855-644-6387
  • Fax:
Mailing address:
  • Phone: 434-409-4108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number1027419
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number1027419
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4351045918
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4301512371
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: