Provider Demographics
NPI:1760476071
Name:FERRELL, LYDIA H (MD)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:H
Last Name:FERRELL
Suffix:
Gender:F
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:PO BOX 3046
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3046
Mailing Address - Country:US
Mailing Address - Phone:317-567-2180
Mailing Address - Fax:317-614-9655
Practice Address - Street 1:6325 S EAST ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-7110
Practice Address - Country:US
Practice Address - Phone:317-781-0067
Practice Address - Fax:317-791-1242
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-01
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056802207L00000X
IN01056802A207LP2900X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000571185OtherANTHEM
IN200526170Medicaid
INM400061636Medicare PIN
INI35657Medicare UPIN
IN256860AMedicare PIN