Provider Demographics
NPI:1801891387
Name:FARRIS, MICHAEL JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:FARRIS
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 1:1411 13000 RD
Mailing Address - Street 2:
Mailing Address - City:ALTAMONT
Mailing Address - State:KS
Mailing Address - Zip Code:67330-9305
Mailing Address - Country:US
Mailing Address - Phone:620-423-2051
Mailing Address - Fax:
Practice Address - Street 1:113 W HICKORY ST
Practice Address - Street 2:
Practice Address - City:NEOSHO
Practice Address - State:MO
Practice Address - Zip Code:64850
Practice Address - Country:US
Practice Address - Phone:417-455-4276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0430692207P00000X, 207Q00000X
ARE-14204207P00000X, 207Q00000X
MO2014009219207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2500021669OtherBNDD
MO2014009219OtherSTATE LICENSE
KS0430692OtherSTATE LICENSE
KS200263590AMedicaid
KS200263590AMedicaid
MOFF4501462OtherDEA