Provider Demographics
NPI:1467563460
Name:FERRELL, TIMMY ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:TIMMY
Middle Name:ALAN
Last Name:FERRELL
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 1:10520 N PAYMENT PEAK RD
Mailing Address - Street 2:
Mailing Address - City:HAUSER
Mailing Address - State:ID
Mailing Address - Zip Code:83854-4524
Mailing Address - Country:US
Mailing Address - Phone:208-619-9334
Mailing Address - Fax:
Practice Address - Street 1:5325 FARAON ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3488
Practice Address - Country:US
Practice Address - Phone:816-271-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM12915208100000X, 208100000X
MO2017039277208100000X
MO2005016628208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MN250000966Medicare PIN