Provider Demographics
NPI:1558335604
Name:FERGUSON, BERNARD J IV (MD)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:J
Last Name:FERGUSON
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-5762
Mailing Address - Country:US
Mailing Address - Phone:860-536-3027
Mailing Address - Fax:
Practice Address - Street 1:365 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4700
Practice Address - Country:US
Practice Address - Phone:860-442-0711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT026962207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D02883Medicare UPIN