Provider Demographics
NPI:1386947331
Name:MICHAEL T GOLDFARB MD PC
Entity type:Organization
Organization Name:MICHAEL T GOLDFARB MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:GOLDFARB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-563-1212
Mailing Address - Street 1:2051 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2920
Mailing Address - Country:US
Mailing Address - Phone:313-563-1212
Mailing Address - Fax:313-563-6069
Practice Address - Street 1:2051 MONROE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2920
Practice Address - Country:US
Practice Address - Phone:313-563-1212
Practice Address - Fax:313-563-6069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301045024207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIA78753Medicare UPIN
MI0824527Medicare PIN