Healthcare Provider Details

I. General information

NPI: 1255793493
Provider Name (Legal Business Name): KELSEY A. EGAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2016
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 HARRISON AVE # MENINO4
BOSTON MA
02118-2905
US

IV. Provider business mailing address

720 HARRISON AVE # DOB503
BOSTON MA
02118-2371
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-4511
  • Fax: 617-414-3171
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number278435
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: