Healthcare Provider Details

I. General information

NPI: 1366424780
Provider Name (Legal Business Name): SUSAN LYNNE FARBER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 MISSLE AVE
MINOT AFB ND
58705-5003
US

IV. Provider business mailing address

164 DELTA DR
MINOT AFB ND
58704-1301
US

V. Phone/Fax

Practice location:
  • Phone: 701-723-5454
  • Fax: 701-723-5769
Mailing address:
  • Phone: 701-727-6904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD0000030948
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: