Provider Demographics
NPI:1639167901
Name:FARABAUGH, WILLIAM NORVAL (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:NORVAL
Last Name:FARABAUGH
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 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:1815 E IRELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2845
Practice Address - Country:US
Practice Address - Phone:574-647-1700
Practice Address - Fax:574-647-7572
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059548A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00142860OtherRR MEDICARE
IN000000334831OtherBCBS BMG IRELAND RD
IN200491800Medicaid
IN000000588554OtherBCBS E BLAIR WARNER
IN000000588554OtherBCBS E BLAIR WARNER
IN000000334831OtherBCBS BMG IRELAND RD
IN169380RRRRMedicare PIN
INP00142860OtherRR MEDICARE