Basic Information
| Provider Information | |||||||||
| NPI: | 1801891387 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARRIS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1411 13000 RD | ||||||||
| Address2: | |||||||||
| City: | ALTAMONT | ||||||||
| State: | KS | ||||||||
| PostalCode: | 673309305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6204232051 | ||||||||
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| Practice Location | |||||||||
| Address1: | 113 W HICKORY ST | ||||||||
| Address2: | |||||||||
| City: | NEOSHO | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4174554276 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 09/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 0430692 | KS | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | E-14204 | AR | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 2014009219 | MO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 0430692 | KS | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | E-14204 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2500021669 | 01 | MO | BNDD | OTHER | BF6852506 | 01 | KS | DEA | OTHER | 2014009219 | 01 | MO | STATE LICENSE | OTHER | 0430692 | 01 | KS | STATE LICENSE | OTHER | 200263590A | 05 | KS | MEDICAID | FF4501462 | 01 | MO | DEA | OTHER |