=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922565720
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES ALEXANDER FERGUSON IV PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2019
-----------------------------------------------------
Last Update Date | 02/27/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 BAUDER CT
-----------------------------------------------------
City | SIMPSONVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29681-8320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-921-2722
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 BAUDER CT
-----------------------------------------------------
City | SIMPSONVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29681-8320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-921-2722
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 4159
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------