1356689103 NPI number — MIKI L FERGUSON APRN

Table of content: MIKI L FERGUSON APRN (NPI 1356689103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356689103 NPI number — MIKI L FERGUSON APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERGUSON
Provider First Name:
MIKI
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

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:
1356689103
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776347
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-6347
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-272-5052
Provider Business Mailing Address Fax Number:
502-629-6217

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4950 NORTON HEALTHCARE BOULEVARD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40241-2848
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-394-6350
Provider Business Practice Location Address Fax Number:
502-394-6363
Provider Enumeration Date:
01/29/2013

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: 363L00000X , with the licence number:  3007704 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100234060 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201140060 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 144543 . This is a "SIHO - NNIKY" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000802747 . This is a "ANTHEM - NNIKY" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 50047890 . This is a "PASSPORT - NNI" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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