Healthcare Provider Details

I. General information

NPI: 1669452934
Provider Name (Legal Business Name): JONATHAN L. FERGUSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 09/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

698 FEATHERSTONE RD
ROCKFORD IL
61107-6303
US

IV. Provider business mailing address

698 FEATHERSTONE RD
ROCKFORD IL
61107-6303
US

V. Phone/Fax

Practice location:
  • Phone: 815-398-3277
  • Fax: 815-484-7001
Mailing address:
  • Phone: 815-398-3277
  • Fax: 815-484-7001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number036078516
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: