Basic Information
| Provider Information | |||||||||
| NPI: | 1417034968 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FARRELL | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | RUSSELL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 328 N MICHIGAN ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466011244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746471842 | ||||||||
| FaxNumber: | 5746471825 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 N MICHIGAN ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466011033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746477459 | ||||||||
| FaxNumber: | 5746473658 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207P00000X | 01041908A | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3037390 | 05 | MI | MEDICAID |