Provider Demographics
NPI:1477703924
Name:RENA FERGUSON, MD, PC
Entity Type:Organization
Organization Name:RENA FERGUSON, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:GMYTRASIEWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-689-5390
Mailing Address - Street 1:128 OLD TOWN RD
Mailing Address - Street 2:SUITE C & D
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-2064
Mailing Address - Country:US
Mailing Address - Phone:631-689-5390
Mailing Address - Fax:631-689-5395
Practice Address - Street 1:128 OLD TOWN RD
Practice Address - Street 2:SUITE C & D
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-2064
Practice Address - Country:US
Practice Address - Phone:631-689-5390
Practice Address - Fax:631-689-5395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-21
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2303302084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY388BK1Medicare PIN