Provider Demographics
NPI:1043284649
Name:FARRELL, JOHN JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JOSEPH
Last Name:FARRELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 NE GLEN OAK AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3252
Mailing Address - Country:US
Mailing Address - Phone:309-624-8749
Mailing Address - Fax:
Practice Address - Street 1:DEPARTMENT OF INTERNAL MEDICINE
Practice Address - Street 2:530 NE GLEN OAK DRIVE
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-655-7734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111223207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL0104OtherJOHN DEERE
IL036111223Medicaid
IL07215036OtherBCBS
ILK06586Medicare ID - Type UnspecifiedINDIVIDUAL #
ILCA4079Medicare ID - Type UnspecifiedRR GROUP #
ILIL0104OtherJOHN DEERE
ILH09576Medicare UPIN
IL639810Medicare ID - Type UnspecifiedMEDICARE
IL036111223Medicaid