=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417136425
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | R D FERGUSON DO, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2007
-----------------------------------------------------
Last Update Date | 11/07/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2390 MITCHELL PARK DR UNIT C
-----------------------------------------------------
City | PETOSKEY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49770-8965
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-348-1968
-----------------------------------------------------
Fax | 231-348-1969
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2390 MITCHELL PARK DR UNIT C
-----------------------------------------------------
City | PETOSKEY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49770-8965
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-348-1968
-----------------------------------------------------
Fax | 231-348-1969
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | TERESA G HUDSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 231-487-1141
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 5101012069
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------