1689719551 NPI number — MELANIE A. FARRELL, M.D., A PROFESSIONAL MEDICAL CORPORATION

Table of content: (NPI 1689719551)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689719551 NPI number — MELANIE A. FARRELL, M.D., A PROFESSIONAL MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MELANIE A. FARRELL, M.D., A PROFESSIONAL MEDICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689719551
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9834 GENESEE AVE
Provider Second Line Business Mailing Address:
SUITE 312
Provider Business Mailing Address City Name:
LA JOLLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92037-1223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-558-7852
Provider Business Mailing Address Fax Number:
858-558-7601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9834 GENESEE AVE
Provider Second Line Business Practice Location Address:
SUITE 312
Provider Business Practice Location Address City Name:
LA JOLLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92037-1223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-558-7852
Provider Business Practice Location Address Fax Number:
858-558-7601
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FARRELL
Authorized Official First Name:
MELANIE
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
858-558-7852

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , with the licence number:  G61110 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G611100 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00G611100 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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