Basic Information
| Provider Information | |||||||||
| NPI: | 1891052817 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARLEY | ||||||||
| FirstName: | LEAH | ||||||||
| MiddleName: | F. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAGLUND | ||||||||
| OtherFirstName: | LEAH | ||||||||
| OtherMiddleName: | F. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1905 E. HUEBBE PARKWAY | ||||||||
| Address2: | BELOIT HEALTH SYSTEM INC | ||||||||
| City: | BELOIT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535111842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083642200 | ||||||||
| FaxNumber: | 6083637395 | ||||||||
| Practice Location | |||||||||
| Address1: | 1905 E. HUEBBE PARKWAY | ||||||||
| Address2: | BELOIT CLINIC | ||||||||
| City: | BELOIT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535111842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083642200 | ||||||||
| FaxNumber: | 6083637368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2012 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 8781005-1205 | UT | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 67514-20 | WI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.