Basic Information
| Provider Information | |||||||||
| NPI: | 1356372759 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARRELL | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BURR | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 780982 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191780982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 W JOHN ROWAN BLVD STE E | ||||||||
| Address2: | |||||||||
| City: | BARDSTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400042636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028949494 | ||||||||
| FaxNumber: | 5028949404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 05/05/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MO2005039869 | MO | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VG0400X | MO2005039869 | MO | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207V00000X | 42828 | KY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VX0000X | MO2005039869 | MO | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics |
ID Information
| ID | Type | State | Issuer | Description | NOO72D | 05 | SC | MEDICAID | 7100087230 | 05 | KY | MEDICAID | 5909940 | 05 | NC | MEDICAID |