1710105333 NPI number — C. GLEN FERGUSON D.O. P.C.

Table of content: (NPI 1710105333)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710105333 NPI number — C. GLEN FERGUSON D.O. P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
C. GLEN FERGUSON D.O. P.C.
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:
1710105333
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 570
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUEBLO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81002-0570
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-296-5840
Provider Business Mailing Address Fax Number:
719-542-0746

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1615 BONFORTE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81001-1602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-296-5840
Provider Business Practice Location Address Fax Number:
719-542-0746
Provider Enumeration Date:
04/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FERGUSON
Authorized Official First Name:
C.
Authorized Official Middle Name:
GLEN
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
719-296-5840

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  17205 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01172055 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: FE03792 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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