Provider Demographics
NPI:1790728012
Name:HOMER A FERGUSON, JR, MD, PC
Entity Type:Organization
Organization Name:HOMER A FERGUSON, JR, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HOMER
Authorized Official - Middle Name:A
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:618-277-1130
Mailing Address - Street 1:3990 N ILLINOIS
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226
Mailing Address - Country:US
Mailing Address - Phone:618-277-1130
Mailing Address - Fax:618-277-6651
Practice Address - Street 1:3990 N ILLINOIS
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226
Practice Address - Country:US
Practice Address - Phone:618-277-1130
Practice Address - Fax:618-277-6651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1225033178OtherNPI INDIVIDUAL
ILDG1184Medicare PIN
ILD15216Medicare UPIN
IL213700Medicare PIN