Provider Demographics
NPI:1881633766
Name:FARLESS, BLAINE LEE (MD)
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:LEE
Last Name:FARLESS
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 1:2010 W KATHERINE P RAINES RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76033-7435
Mailing Address - Country:US
Mailing Address - Phone:817-556-3212
Mailing Address - Fax:817-556-2388
Practice Address - Street 1:2010 W KATHERINE P RAINES RD
Practice Address - Street 2:SUITE 300
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-7435
Practice Address - Country:US
Practice Address - Phone:817-556-3212
Practice Address - Fax:817-556-2388
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1659207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX047918001Medicaid
TX047918001Medicaid
TX89T620Medicare PIN