Provider Demographics
NPI:1194724724
Name:FARRELL, JOHN S (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:FARRELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 584A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-6966
Mailing Address - Fax:314-251-6632
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 584A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-6966
Practice Address - Fax:314-251-6632
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR5636207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200162204Medicaid
R5636Medicare UPIN