Provider Demographics
NPI:1760475784
Name:FARRELL, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
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 1:4417 VESTAL PKWY E
Mailing Address - Street 2:SUITE 300
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-3556
Mailing Address - Country:US
Mailing Address - Phone:607-240-2885
Mailing Address - Fax:607-240-2886
Practice Address - Street 1:4417 VESTAL PARKWAY EAST
Practice Address - Street 2:SUITE 300
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-3556
Practice Address - Country:US
Practice Address - Phone:607-240-2885
Practice Address - Fax:607-240-2886
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203308208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01668299Medicaid
NY01668299Medicaid
NYJ400059234Medicare PIN