1851586804 NPI number — CORY DAVID FERGUSON D.P.T.

Table of content: SHANNON FISCHER (NPI 1497649628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851586804 NPI number — CORY DAVID FERGUSON D.P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERGUSON
Provider First Name:
CORY
Provider Middle Name:
DAVID
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.P.T.
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:
1851586804
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 N LITCHFIELD RD
Provider Second Line Business Mailing Address:
STE. 155
Provider Business Mailing Address City Name:
GOODYEAR
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85338-1333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-882-9787
Provider Business Mailing Address Fax Number:
623-882-9791

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 N LITCHFIELD RD
Provider Second Line Business Practice Location Address:
STE. 155
Provider Business Practice Location Address City Name:
GOODYEAR
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85338-1333
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-882-9787
Provider Business Practice Location Address Fax Number:
623-882-9791
Provider Enumeration Date:
09/12/2007

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:  6122 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00388070 . This is a "RR MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 64-0096 . This is a "EVERCARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 7499498 . This is a "AETNA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 2Z2985 . This is a "HEALTHNET" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0299850 . This is a "BCBS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 0142085 . This is a "DEPT OF LABOR" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 103195 . This is a "MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 0142085 . This is a "WASH DEPT OF LABOR" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 6122 . This is a "LICENSE #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 916190 . This is a "AHCCCS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 916190 . This is a "MERCY CARE PLAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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