Provider Demographics
NPI:1861994592
Name:FARWELL INTERNAL MEDICINE PLLC
Entity type:Organization
Organization Name:FARWELL INTERNAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:NYAMOGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-544-4226
Mailing Address - Street 1:522 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FARWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48622-9118
Mailing Address - Country:US
Mailing Address - Phone:989-544-4226
Mailing Address - Fax:
Practice Address - Street 1:522 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FARWELL
Practice Address - State:MI
Practice Address - Zip Code:48622-9118
Practice Address - Country:US
Practice Address - Phone:407-288-4140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-08
Last Update Date:2018-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301111706207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty