Provider Demographics
NPI:1033520291
Name:RAUTH-FARLEY, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:RAUTH-FARLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-1239
Mailing Address - Country:US
Mailing Address - Phone:248-824-6600
Mailing Address - Fax:
Practice Address - Street 1:5746 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64118-3998
Practice Address - Country:US
Practice Address - Phone:816-912-5439
Practice Address - Fax:855-813-6442
Is Sole Proprietor?:No
Enumeration Date:2014-05-09
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0430385208000000X, 207Q00000X
MOR1C65208000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine