1962488429 NPI number — CHARLIE FERGUSON MD

Table of content: CHARLIE FERGUSON MD (NPI 1962488429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962488429 NPI number — CHARLIE FERGUSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERGUSON
Provider First Name:
CHARLIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1962488429
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2908 MALL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORENCE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35630-1534
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-767-2702
Provider Business Mailing Address Fax Number:
256-760-1870

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2908 MALL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLORENCE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35630-1534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-767-2702
Provider Business Practice Location Address Fax Number:
256-760-1870
Provider Enumeration Date:
12/16/2005

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: 207Q00000X , with the licence number:  11278 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 11278 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 930023562 . This is a "RAILROAD MCR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3823836 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51014730 . This is a "BLUECROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 11278 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51083625 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: E368 . This is a "MEDICARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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