Provider Demographics
NPI:1164630158
Name:HAROLD A FERGUSON JR
Entity Type:Organization
Organization Name:HAROLD A FERGUSON JR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:937-456-8360
Mailing Address - Street 1:450 B WASHINGTON JACKSON RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:EATON
Mailing Address - State:OH
Mailing Address - Zip Code:45320
Mailing Address - Country:US
Mailing Address - Phone:937-456-8360
Mailing Address - Fax:937-456-8363
Practice Address - Street 1:450 B WASHINGTON JACKSON RD
Practice Address - Street 2:SUITE 102
Practice Address - City:EATON
Practice Address - State:OH
Practice Address - Zip Code:45320
Practice Address - Country:US
Practice Address - Phone:937-456-8360
Practice Address - Fax:937-456-8363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004371207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1659312205OtherINDIVIDUAL NPI
OH0667292Medicaid
OH0667292Medicaid
OH9322511Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER