Provider Demographics
NPI:1437153921
Name:FERRELL, HERMAN L (MD)
Entity type:Individual
Prefix:
First Name:HERMAN
Middle Name:L
Last Name:FERRELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:862 MINARCA DR
Mailing Address - Street 2:
Mailing Address - City:DES PERES
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2047
Mailing Address - Country:US
Mailing Address - Phone:618-482-7242
Mailing Address - Fax:
Practice Address - Street 1:129 N 8TH ST
Practice Address - Street 2:
Practice Address - City:EAST ST LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62201-2917
Practice Address - Country:US
Practice Address - Phone:618-482-7242
Practice Address - Fax:314-810-1399
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036074327207R00000X
MOR7303207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1437153921Medicaid
IL201239043Medicaid
ILA09895Medicare UPIN
MO147480027Medicare PIN
MO1437153921Medicaid