Provider Demographics
NPI:1992917082
Name:FARLESS, LAURA BROOKE (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:BROOKE
Last Name:FARLESS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 GRAYS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31410-1042
Mailing Address - Country:US
Mailing Address - Phone:205-960-5105
Mailing Address - Fax:
Practice Address - Street 1:5354 REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6007
Practice Address - Country:US
Practice Address - Phone:912-819-5999
Practice Address - Fax:912-819-5980
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL27790207R00000X
ORMD28152207R00000X
WAMD00049416207R00000X
GA67414207RH0002X
GA067414207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00481527Medicaid
AL051118053OtherBCBS
AL129907Medicaid
AL129909Medicaid
AL129914Medicaid
AL051118048OtherBCBS
AL129905Medicaid
AL051118052OtherBCBS
AL051118051OtherBCBS
AL129906Medicaid
AL129912Medicaid
AL133118Medicaid
ALZ01903OtherVIVA
AL051118049OtherBCBS
AL051118055OtherBCBS
AL051118047OtherBCBS
AL102I116378Medicare PIN
AL129912Medicaid