Provider Demographics
NPI:1053948497
Name:KELLEGREW, JAY
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:KELLEGREW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 806
Mailing Address - Street 2:
Mailing Address - City:ONSET
Mailing Address - State:MA
Mailing Address - Zip Code:02558-0806
Mailing Address - Country:US
Mailing Address - Phone:978-758-2049
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-7068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2024-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD23922207L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program