MEDICARE: JAMES W FERGUSON MD LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	150415	NY

General Provider Information

NPI Number	:	1336395417
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JAMES W FERGUSON MD LLC

Provider Business Mailing Address
First Line	:	170 W MAIN ST
Second Line	:
City	:	EAST ISLIP
State	:	NY
Zip	:	11730-2216
Country	:	US
Telephone Number	:	631-581-2049
Fax Number	:	631-581-3354

Provider Business Practice Location Address
First Line	:	170 W MAIN ST
Second Line	:
City	:	EAST ISLIP
State	:	NY
Zip	:	11730-2216
Country	:	US
Telephone Number	:	631-581-2049
Fax Number	:	631-581-3354

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JAMES W FERGUSON
Credential	:	MD
Telephone Number	:	631-581-2049

Provider Enumeration Date	:	08/08/2008
Last Update Date	:	08/08/2008

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