Healthcare Provider Details

I. General information

NPI: 1528298924
Provider Name (Legal Business Name): FERGUSON AESTHETIC CARE AND ENHANCEMENT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2009
Last Update Date: 07/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 ROSS CLARK CIR SUITE 210
DOTHAN AL
36301-3001
US

IV. Provider business mailing address

1118 ROSS CLARK CIR SUITE 210
DOTHAN AL
36301-3001
US

V. Phone/Fax

Practice location:
  • Phone: 334-699-3223
  • Fax: 334-699-3169
Mailing address:
  • Phone: 334-699-3223
  • Fax: 334-699-3169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number22347
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number00025142
License Number StateAL

VIII. Authorized Official

Name: DR. JOHN CHRISTIAN FERGUSON
Title or Position: PRESIDENT
Credential: MD
Phone: 334-699-3223