Basic Information
| Provider Information | |||||||||
| NPI: | 1376542290 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERRELL | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | RALPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 GRAND CENTRAL AVE | ||||||||
| Address2: | STE 115 | ||||||||
| City: | VIENNA | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261051079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042952311 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1500 GRAND CENTRAL AVE | ||||||||
| Address2: | STE 115 | ||||||||
| City: | VIENNA | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261051079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042952311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 06/08/2011 | ||||||||
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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 | 207Q00000X | 19776 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 35076392 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 19776 | WV | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1802554000 | 05 | WV | MEDICAID | BF6305951 | 01 | DEA | OTHER |