Provider Demographics
NPI:1417384199
Name:FARMBROOK FAMILY PRACTICE PLLC
Entity Type:Organization
Organization Name:FARMBROOK FAMILY PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREI
Authorized Official - Middle Name:
Authorized Official - Last Name:KATYCHEV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-470-6038
Mailing Address - Street 1:23688 PADDOCK DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-2226
Mailing Address - Country:US
Mailing Address - Phone:248-796-7486
Mailing Address - Fax:
Practice Address - Street 1:29877 TELEGRAPH RD
Practice Address - Street 2:SUITE 302
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1332
Practice Address - Country:US
Practice Address - Phone:248-796-7486
Practice Address - Fax:248-350-3519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-26
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085733302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1417384199Medicaid
MIMI7416Medicare UPIN