Provider Demographics
NPI:1962796862
Name:FARAH, LIBAN (MD)
Entity type:Individual
Prefix:DR
First Name:LIBAN
Middle Name:
Last Name:FARAH
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 1:1100 BERGSLIEN ST
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:WI
Mailing Address - Zip Code:54002-2600
Mailing Address - Country:US
Mailing Address - Phone:715-684-1111
Mailing Address - Fax:715-684-1119
Practice Address - Street 1:1100 BERGSLIEN ST
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:WI
Practice Address - Zip Code:54002-2600
Practice Address - Country:US
Practice Address - Phone:715-684-1111
Practice Address - Fax:715-694-1119
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI56541207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400146922Medicare PIN