Healthcare Provider Details

I. General information

NPI: 1992789507
Provider Name (Legal Business Name): FERGUSON MEDICAL LABORATORIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 01/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W 32ND ST BLDG B SUITE 101
JOPLIN MO
64804-1528
US

IV. Provider business mailing address

PO BOX 20452 FML-CREDENTIALING
COLUMBUS OH
43220-0452
US

V. Phone/Fax

Practice location:
  • Phone: 417-623-6330
  • Fax: 417-623-3950
Mailing address:
  • Phone: 614-442-2406
  • Fax: 614-442-2410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number26D0666300
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number26D0445616
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number26D0445668
License Number StateMO

VIII. Authorized Official

Name: MICHAEL P HURLY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 417-623-6330