1659365872 NPI number — EDRICK JORDAN FERGUSON M.D.

Table of content: EDRICK JORDAN FERGUSON M.D. (NPI 1659365872)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659365872 NPI number — EDRICK JORDAN FERGUSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERGUSON
Provider First Name:
EDRICK
Provider Middle Name:
JORDAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1659365872
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11283
Provider Second Line Business Mailing Address:
MURFREESBORO
Provider Business Mailing Address City Name:
MURFREESBORO
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37129-0026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-519-3993
Provider Business Mailing Address Fax Number:
423-837-9547

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2804 BATTLEGROUND DR
Provider Second Line Business Practice Location Address:
MURFREESBORO
Provider Business Practice Location Address City Name:
MURFREESBORO
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37129-6492
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-519-3993
Provider Business Practice Location Address Fax Number:
423-837-9547
Provider Enumeration Date:
09/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  26307 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 35079693 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2383924 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30885811 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00468253 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1508037 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000270956 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 4191954 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4166295 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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