Provider Demographics
NPI:1972931921
Name:FERRELL, MARK (RT(R))
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:FERRELL
Suffix:
Gender:M
Credentials:RT(R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:PANA
Mailing Address - State:IL
Mailing Address - Zip Code:62557-1869
Mailing Address - Country:US
Mailing Address - Phone:217-825-3677
Mailing Address - Fax:
Practice Address - Street 1:702 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:PANA
Practice Address - State:IL
Practice Address - Zip Code:62557-1869
Practice Address - Country:US
Practice Address - Phone:217-825-3677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL5005017022471C1106X
CARHF000976202471C1106X
SC00-64562471C1106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C1106XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistCardiac-Interventional Technology