Provider Demographics
NPI:1659365872
Name:FERGUSON, EDRICK JORDAN (MD)
Entity Type:Individual
Prefix:
First Name:EDRICK
Middle Name:JORDAN
Last Name:FERGUSON
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:PO BOX 11283
Mailing Address - Street 2:MURFREESBORO
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-0026
Mailing Address - Country:US
Mailing Address - Phone:804-519-3993
Mailing Address - Fax:423-837-9547
Practice Address - Street 1:2804 BATTLEGROUND DR
Practice Address - Street 2:MURFREESBORO
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-6492
Practice Address - Country:US
Practice Address - Phone:804-519-3993
Practice Address - Fax:423-837-9547
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26307208D00000X
OH350796932085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2383924Medicaid
TN30885811Medicaid
P00468253OtherRAILROAD MEDICARE
TN1508037Medicaid
OH000000270956OtherANTHEM
TN4191954OtherBLUE CROSS BLUE SHIELD
TN4166295OtherBCBS PROVIDER NUMBER
OH000000270956OtherANTHEM
TN4191954OtherBLUE CROSS BLUE SHIELD
F96295Medicare UPIN
TN1508037Medicaid