Provider Demographics
NPI:1447399290
Name:FERGUSON, ELAINE FERGINIA (MD)
Entity Type:Individual
Prefix:DR
First Name:ELAINE
Middle Name:FERGINIA
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 W 73RD ST
Mailing Address - Street 2:ROOM 117
Mailing Address - City:BEDFORD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60499-9201
Mailing Address - Country:US
Mailing Address - Phone:708-563-7674
Mailing Address - Fax:708-563-9977
Practice Address - Street 1:6801 W 73RD ST
Practice Address - Street 2:ROOM 117
Practice Address - City:BEDFORD PARK
Practice Address - State:IL
Practice Address - Zip Code:60499-9201
Practice Address - Country:US
Practice Address - Phone:708-563-7674
Practice Address - Fax:708-563-9977
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4C3857Medicare UPIN
IL206588Medicare ID - Type Unspecified