Basic Information
| Provider Information | |||||||||
| NPI: | 1174552079 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FARAH | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | ANDREW | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751803 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367183550 | ||||||||
| FaxNumber: | 3362771825 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 KIMEL PARK DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271036951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367183550 | ||||||||
| FaxNumber: | 3362771825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2006 | ||||||||
| LastUpdateDate: | 10/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 34308 | NC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 31135 | 01 | NC | BLUE CROSS/BLUE SHIELD | OTHER | 8931135 | 05 | NC | MEDICAID | 28991 | 01 | NC | CIGNA | OTHER | 118421-000 | 01 | NC | MAGELLAN BH | OTHER | B0677 | 01 | NC | MEDCOST | OTHER |