Healthcare Provider Details

I. General information

NPI: 1972931921
Provider Name (Legal Business Name): MARK FERRELL RT(R)
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 SPRUCE ST
PANA IL
62557-1869
US

IV. Provider business mailing address

702 SPRUCE ST
PANA IL
62557-1869
US

V. Phone/Fax

Practice location:
  • Phone: 217-825-3677
  • Fax:
Mailing address:
  • Phone: 217-825-3677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C1106X
TaxonomyCardiac-Interventional Technology Radiologic Technologist
License Number500501702
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2471C1106X
TaxonomyCardiac-Interventional Technology Radiologic Technologist
License NumberRHF00097620
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2471C1106X
TaxonomyCardiac-Interventional Technology Radiologic Technologist
License Number00-6456
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: