Provider Demographics
NPI:1710161815
Name:FREDERICK FERGUSON MD PA
Entity Type:Organization
Organization Name:FREDERICK FERGUSON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-655-1025
Mailing Address - Street 1:100 NW 170TH ST
Mailing Address - Street 2:301
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5513
Mailing Address - Country:US
Mailing Address - Phone:305-655-1025
Mailing Address - Fax:305-652-9530
Practice Address - Street 1:100 NW 170TH ST
Practice Address - Street 2:301
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33169-5513
Practice Address - Country:US
Practice Address - Phone:305-655-1025
Practice Address - Fax:305-652-9530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75338207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty