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NPI Code Detail

MEDICARE: DR. KELLY M FARROLL MD

MEDICARE: DR. KELLY M FARROLL MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207P00000XEmergency Medicine Physician036-093514IL
2207Q00000XFamily Medicine Physician036093514IL

General Provider Information

NPI Number : 1063503704
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. KELLY M FARROLL MD
Provider Business Mailing Address
First Line : 2166 MADISON AVE
Second Line :
City : GRANITE CITY
State : IL
Zip : 62040-4700
Country : US
Telephone Number : 618-452-3301
Fax Number : 618-452-3312
Provider Business Practice Location Address
First Line : 2166 MADISON AVE
Second Line :
City : GRANITE CITY
State : IL
Zip : 62040-4700
Country : US
Telephone Number : 618-452-3301
Fax Number : 618-452-3312
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/27/2006
Last Update Date : 02/08/2023

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Directions to “ DR. KELLY M FARROLL MD” Practice Location

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