Provider Demographics
NPI:1417136425
Name:R D FERGUSON DO, PC
Entity Type:Organization
Organization Name:R D FERGUSON DO, PC
Other - Org Name:LITTLE TRAVERSE BAY FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:G
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-487-1141
Mailing Address - Street 1:2390 MITCHELL PARK DR
Mailing Address - Street 2:UNIT C
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8965
Mailing Address - Country:US
Mailing Address - Phone:231-348-1968
Mailing Address - Fax:231-348-1969
Practice Address - Street 1:2390 MITCHELL PARK DR
Practice Address - Street 2:UNIT C
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8965
Practice Address - Country:US
Practice Address - Phone:231-348-1968
Practice Address - Fax:231-348-1969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012069207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4830173Medicaid
MI0P27000Medicare UPIN