Basic Information
| Provider Information | |||||||||
| NPI: | 1760476071 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERRELL | ||||||||
| FirstName: | LYDIA | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3046 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462063046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175672180 | ||||||||
| FaxNumber: | 3176149655 | ||||||||
| Practice Location | |||||||||
| Address1: | 6325 S EAST ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462277110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177810067 | ||||||||
| FaxNumber: | 3177911242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2005 | ||||||||
| LastUpdateDate: | 04/05/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 01056802 | IN | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 01056802A | IN | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0000X | 01056802A | IN | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000571185 | 01 | IN | ANTHEM | OTHER | 200526170 | 05 | IN | MEDICAID |