Provider Demographics
NPI:1033319389
Name:FARRELL, KATHRYN R (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:R
Last Name:FARRELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5 RIVER BEND PL
Mailing Address - Street 2:SUITE C
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39232-7618
Mailing Address - Country:US
Mailing Address - Phone:601-957-7345
Mailing Address - Fax:769-251-5429
Practice Address - Street 1:5 RIVER BEND PL
Practice Address - Street 2:SUITE C
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39232-7618
Practice Address - Country:US
Practice Address - Phone:601-957-7345
Practice Address - Fax:769-251-5429
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS201822080N0001X
MO2012013848208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09571374Medicaid