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General NPI Number Information
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NPI Number | 1477703924
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Entity Type | Organization
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Legal Business Name | RENA FERGUSON, MD, PC
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Dates
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Enumeration Date | 09/21/2008
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Last Update Date | 10/14/2008
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Provider Practice Location Address
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Address Line | 128 OLD TOWN RD SUITE C & D
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City | SETAUKET
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State | NY
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Zip | 11733-2064
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Country | US
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Telephone | 631-689-5390
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Fax | 631-689-5395
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Provider Business Mailing Address
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Address Line | 128 OLD TOWN RD SUITE C & D
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City | SETAUKET
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State | NY
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Zip | 11733-2064
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Country | US
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Telephone | 631-689-5390
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Fax | 631-689-5395
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Authorized Official
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Title or Position | CONSULTANT
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Name | GEORGE GMYTRASIEWICZ
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Credential |
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Telephone | 631-689-5390
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 230330
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License Number State | NY
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