1841480365 NPI number — KRISTY LYNN FERGUSON MPT

Table of content: CINDY TRINH OD (NPI 1164908679)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841480365 NPI number — KRISTY LYNN FERGUSON MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERGUSON
Provider First Name:
KRISTY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KNOBLAUCH
Provider Other First Name:
KRISTY
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1841480365
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2454 W CLAY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CHARLES
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63301-2548
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-916-4625
Provider Business Mailing Address Fax Number:
636-916-4628

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4800 MEXICO RD
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
SAINT PETERS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63376-1666
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-939-9540
Provider Business Practice Location Address Fax Number:
636-939-9886
Provider Enumeration Date:
07/31/2007

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:  2007022058 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00423550 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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