Basic Information
| Provider Information | |||||||||
| NPI: | 1841268166 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARRELL | ||||||||
| FirstName: | DINA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 346 GRAND AVE | ||||||||
| Address2: | UNITED MEDICAL ASSOC PC | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077700025 | ||||||||
| FaxNumber: | 6077293982 | ||||||||
| Practice Location | |||||||||
| Address1: | 33-57 HARRISON ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077636412 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2006 | ||||||||
| LastUpdateDate: | 11/18/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2033071 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01665618 | 05 | NY | MEDICAID |