Healthcare Provider Details

I. General information

NPI: 1659365872
Provider Name (Legal Business Name): EDRICK JORDAN FERGUSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W WALNUT ST
CANTON IL
61520-2444
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2500
US

V. Phone/Fax

Practice location:
  • Phone: 309-647-5240
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35079693
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number26307
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036170509
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: