Provider Demographics
NPI:1568446409
Name:DAVENPORT FERGUSON PHYSICIAN GROUP PLLC
Entity Type:Organization
Organization Name:DAVENPORT FERGUSON PHYSICIAN GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARGO
Authorized Official - Middle Name:KIMBERLEE
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-968-4470
Mailing Address - Street 1:15565 NORTHLAND DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-5310
Mailing Address - Country:US
Mailing Address - Phone:248-423-4477
Mailing Address - Fax:248-423-4488
Practice Address - Street 1:15565 NORTHLAND DR
Practice Address - Street 2:SUITE 204
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-5310
Practice Address - Country:US
Practice Address - Phone:248-423-4477
Practice Address - Fax:248-423-4488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-05
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061334207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4495238-10Medicaid
MI080F300760OtherBCN
MI080F300760OtherBC GROUP
MI0N67980Medicare PIN