Provider Demographics
NPI:1174772057
Name:FARMBROOK INTERNAL MEDICINE INC
Entity type:Organization
Organization Name:FARMBROOK INTERNAL MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:N
Authorized Official - Last Name:HAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-593-0575
Mailing Address - Street 1:31500 TELEGRAPH RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-4313
Mailing Address - Country:US
Mailing Address - Phone:248-593-0575
Mailing Address - Fax:248-433-3452
Practice Address - Street 1:31500 TELEGRAPH RD
Practice Address - Street 2:SUITE 130
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4313
Practice Address - Country:US
Practice Address - Phone:248-593-0575
Practice Address - Fax:248-433-3452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-16
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012230261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI199809Medicaid
MIG25356OtherBLUE CROSS UPIN
MI5631503OtherBCBSM PROVIDER CODE
MI199809Medicaid