1215276548 NPI number — TARA M FERGUSON DOCTORATE OF PHYSICA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215276548 NPI number — TARA M FERGUSON DOCTORATE OF PHYSICA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERGUSON
Provider First Name:
TARA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DOCTORATE OF PHYSICA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MINKUS
Provider Other First Name:
TARA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DOCTORATE OF PHYSICA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1215276548
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
625 LINCOLN AVE
Provider Second Line Business Mailing Address:
SUITE 209
Provider Business Mailing Address City Name:
NORTH CHARLEROI
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15022-2451
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-483-3610
Provider Business Mailing Address Fax Number:
724-489-4758

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
605 SCENERY DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELIZABETH
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15037-2000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-751-0040
Provider Business Practice Location Address Fax Number:
412-751-0041
Provider Enumeration Date:
02/06/2013

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: 225100000X , with the licence number:  PT022583 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1027971610001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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