Healthcare Provider Details

I. General information

NPI: 1740366244
Provider Name (Legal Business Name): KENNETH D FARR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 W ILES AVE
SPRINGFIELD IL
62704-4174
US

IV. Provider business mailing address

10 WILLIAM POPE DRIVE SUNGATE MEDICAL CENTER
BLUFFON SC
29909
US

V. Phone/Fax

Practice location:
  • Phone: 217-698-3030
  • Fax:
Mailing address:
  • Phone: 843-842-2020
  • Fax: 843-705-1512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number16864
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: