Basic Information
| Provider Information | |||||||||
| NPI: | 1255705497 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AHMAD FARAH DPM PC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FARAH PODIATRY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2105 WEST RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | TRENTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481833897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346757777 | ||||||||
| FaxNumber: | 7346757785 | ||||||||
| Practice Location | |||||||||
| Address1: | 2105 WEST RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | TRENTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481833897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346757777 | ||||||||
| FaxNumber: | 7346757785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2015 | ||||||||
| LastUpdateDate: | 11/28/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FARAH | ||||||||
| AuthorizedOfficialFirstName: | AHMAD | ||||||||
| AuthorizedOfficialMiddleName: | RAFEEK | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7346757777 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 5901002222 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1285730531 | 01 | INDIVIDUAL MEDICARE NPI | OTHER |