Basic Information
Provider Information | |||||||||
NPI: | 1740238849 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FARRELL | ||||||||
FirstName: | PATRICK | ||||||||
MiddleName: | EDWARD | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FARRELL, LLC | ||||||||
OtherFirstName: | DR | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 967 E PARKCENTER BLVD | ||||||||
Address2: | # 273 | ||||||||
City: | BOISE | ||||||||
State: | ID | ||||||||
PostalCode: | 837066721 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2089558215 | ||||||||
FaxNumber: | 2084455899 | ||||||||
Practice Location | |||||||||
Address1: | 301 W MYRTLE ST | ||||||||
Address2: |   | ||||||||
City: | BOISE | ||||||||
State: | ID | ||||||||
PostalCode: | 837027656 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2089558215 | ||||||||
FaxNumber: | 2084455899 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2006 | ||||||||
LastUpdateDate: | 01/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | M6441 | ID | Y |   | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 003692900 | 05 | ID |   | MEDICAID | 000010158339 | 01 | ID | BLUE SHIELD OF IDAHO | OTHER | 76755 | 01 | ID | BLUE CROSS OF IDAHO | OTHER |