Provider Demographics
NPI:1578507273
Name:FARAH, KATHLEEN S (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:S
Last Name:FARAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2321 STOUT RD
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-7003
Mailing Address - Country:US
Mailing Address - Phone:715-235-5531
Mailing Address - Fax:715-233-7645
Practice Address - Street 1:2321 STOUT RD
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-7003
Practice Address - Country:US
Practice Address - Phone:715-235-5531
Practice Address - Fax:715-233-7645
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25580207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30563100Medicaid
B52705Medicare UPIN