Basic Information
| Provider Information | |||||||||
| NPI: | 1033420179 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FARRELLY | ||||||||
| FirstName: | CORMAC | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 51 N. 39TH STREET | ||||||||
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| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191042614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156628000 | ||||||||
| FaxNumber: | 2156627011 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 SPRUCE ST | ||||||||
| Address2: | GROUND FLOOR DULLES | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156623005 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2010 | ||||||||
| LastUpdateDate: | 10/10/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD440265 | PA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | MD440265 | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.