Healthcare Provider Details

I. General information

NPI: 1467577874
Provider Name (Legal Business Name): MPFERGUS, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 04/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13025 CONIFER ST
PLAINFIELD IL
60585-2989
US

IV. Provider business mailing address

PO BOX 986
PLAINFIELD IL
60544-0986
US

V. Phone/Fax

Practice location:
  • Phone: 630-253-8814
  • Fax: 815-230-2608
Mailing address:
  • Phone: 630-253-8814
  • Fax: 815-230-2608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number042.618333
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier9932261
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerBCBS

VIII. Authorized Official

Name: DR. MICHAEL P FERGUS
Title or Position: OWNER
Credential: DC
Phone: 630-253-8814