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

Table of content: CORY DAVID FERGUSON D.P.T. (NPI 1851586804)

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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