Provider Demographics
NPI:1972649630
Name:JOHANN FARLEY MD PC
Entity Type:Organization
Organization Name:JOHANN FARLEY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHANN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:FARLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-801-2665
Mailing Address - Street 1:8300 BROADWAY STE D2
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-8603
Mailing Address - Country:US
Mailing Address - Phone:219-649-0044
Mailing Address - Fax:219-649-0055
Practice Address - Street 1:8300 BROADWAY STE D2
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-8603
Practice Address - Country:US
Practice Address - Phone:219-649-0044
Practice Address - Fax:219-649-0055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060680A261QP2300X
WI46905-20261QP2300X
CAA89493261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
INI31804Medicare UPIN