Provider Demographics
NPI:1457318768
Name:FERGUSON, VICTORIA (CNM)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5619-25 VINE STREET
Mailing Address - Street 2:SPECTRUM HEALTH SERVICES, INC.
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-1302
Mailing Address - Country:US
Mailing Address - Phone:215-471-2761
Mailing Address - Fax:215-471-2929
Practice Address - Street 1:1415 NORTH BROAD STREET
Practice Address - Street 2:SUITE 224 BROAD STREET HEALTH CENTER
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19122-3323
Practice Address - Country:US
Practice Address - Phone:215-235-7944
Practice Address - Fax:215-235-3361
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMW010066367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101031434Medicaid
PA101031434Medicaid
PA079995Medicare ID - Type Unspecified