Provider Demographics
NPI:1689719551
Name:MELANIE A. FARRELL, M.D., A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MELANIE A. FARRELL, M.D., A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:FARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-558-7852
Mailing Address - Street 1:9834 GENESEE AVE
Mailing Address - Street 2:SUITE 312
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1223
Mailing Address - Country:US
Mailing Address - Phone:858-558-7852
Mailing Address - Fax:858-558-7601
Practice Address - Street 1:9834 GENESEE AVE
Practice Address - Street 2:SUITE 312
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1223
Practice Address - Country:US
Practice Address - Phone:858-558-7852
Practice Address - Fax:858-558-7601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61110207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G611100OtherBLUE SHIELD
CA00G611100Medicaid
CA00G611100Medicaid