Basic Information
| Provider Information | |||||||||
| NPI: | 1265494959 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FARRA | ||||||||
| FirstName: | FREDERIC | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 CAMPUS BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406620306 | ||||||||
| FaxNumber: | 5405421843 | ||||||||
| Practice Location | |||||||||
| Address1: | 190 CAMPUS BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406620306 | ||||||||
| FaxNumber: | 5405421843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 01/06/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 0101041773 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 0101041773 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RI0011X | 25172 | WV | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | P00656329 | 01 | RAILROAD MEDICARE | OTHER | 000875693 | 01 | WV BLUE SHIELD GROUP # | OTHER | 006056954 | 05 | VA | MEDICAID | 006056954 | 01 | VA MEDICAID PROFESSIONAL | OTHER | 550941600 | 01 | MD | MD MEDICAID GROUP | OTHER | C00085 | 01 | VA MEDICARE B GROUP # | OTHER | 072370 | 01 | ANTHEM PROFESSIONAL | OTHER | 286101100 | 05 | MD | MEDICAID | 3810003817 | 01 | WV | WV MEDICAID GROUP | OTHER | 08243200000 | 01 | QUALCHOICE PROFESSIONAL | OTHER | 2119636 | 01 | MAMSI PROFESSIONAL | OTHER | 44153 | 01 | SENTARA PROFESSIONAL | OTHER | 001717440 | 01 | WV BLUE SHIELD | OTHER | 0085544000 | 05 | WV | MEDICAID |