Healthcare Provider Details

I. General information

NPI: 1699799049
Provider Name (Legal Business Name): FERGUSON MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 06/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 N MAIN ST
SIKESTON MO
63801-5044
US

IV. Provider business mailing address

PO BOX 1068
SIKESTON MO
63801-1068
US

V. Phone/Fax

Practice location:
  • Phone: 573-471-0330
  • Fax: 573-472-2966
Mailing address:
  • Phone: 573-471-0330
  • Fax: 573-472-2966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES SHILL
Title or Position: CEO
Credential:
Phone: 573-471-0330