1114101912 NPI number — JAMES D. FERGUSON OD PC

Table of content: (NPI 1114101912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114101912 NPI number — JAMES D. FERGUSON OD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JAMES D. FERGUSON OD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114101912
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8417 KENNEDY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIGHLAND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46322-1139
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-838-2020
Provider Business Mailing Address Fax Number:
219-838-0454

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1820 E COLUMBUS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST CHICAGO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46312-2826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-398-2020
Provider Business Practice Location Address Fax Number:
291-398-9808
Provider Enumeration Date:
12/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
219-972-0904

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  18002583A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200323790 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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