Provider Demographics
NPI:1497038129
Name:FARRELL, COLLEEN ANN (MD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ANN
Last Name:FARRELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:FARRELL
Other - Last Name:SELIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1200 CENTRE ST
Mailing Address - Street 2:DEPARTMENT OF MEDICINE
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-1000
Mailing Address - Country:US
Mailing Address - Phone:617-363-8010
Mailing Address - Fax:617-363-8929
Practice Address - Street 1:1200 CENTRE ST
Practice Address - Street 2:DEPARTMENT OF MEDICINE
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-1000
Practice Address - Country:US
Practice Address - Phone:617-363-8010
Practice Address - Fax:617-363-8929
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT022648207Q00000X
MA255689207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400183612Medicare UPIN