Provider Demographics
NPI:1487726972
Name:FARRELL, GREGG M (MD)
Entity type:Individual
Prefix:
First Name:GREGG
Middle Name:M
Last Name:FARRELL
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 1:324 GANNETT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3266
Mailing Address - Country:US
Mailing Address - Phone:207-482-7800
Mailing Address - Fax:
Practice Address - Street 1:360 BROADWAY
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3979
Practice Address - Country:US
Practice Address - Phone:207-262-1464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD10626207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MED03542Medicare UPIN
MEMM0191Medicare ID - Type Unspecified
ME018105OtherANTHEM
MEAA17265OtherHPHC
AX6947Medicare PIN
ME3240685OtherAETNA
MEM80679OtherCIGNA
ME284750099Medicaid
ME05004496Medicare ID - Type UnspecifiedRAILROAD
NH30201121Medicaid