Provider Demographics
NPI:1639157936
Name:FERGUS, PETER (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:FERGUS
Suffix:
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 1:1727 SHAWANO AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-3273
Mailing Address - Country:US
Mailing Address - Phone:920-272-1050
Mailing Address - Fax:920-272-1051
Practice Address - Street 1:1727 SHAWANO AVE
Practice Address - Street 2:STE 201
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3273
Practice Address - Country:US
Practice Address - Phone:920-272-1050
Practice Address - Fax:920-272-1051
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19406207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30979800Medicaid
WI110149556OtherRAILROAD MEDICARE
WIB52750Medicare UPIN
WIB52750Medicare UPIN
WI000307255Medicare ID - Type Unspecified