Provider Demographics
NPI:1821218793
Name:MERVIN J. WEIS & BRUCE L. FERGUSON MD, SC
Entity Type:Organization
Organization Name:MERVIN J. WEIS & BRUCE L. FERGUSON MD, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:L
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-769-4413
Mailing Address - Street 1:4640 N MARINE DR
Mailing Address - Street 2:STE C 6100
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5719
Mailing Address - Country:US
Mailing Address - Phone:773-769-4413
Mailing Address - Fax:773-769-5140
Practice Address - Street 1:4640 N MARINE DR
Practice Address - Street 2:STE C 6100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5719
Practice Address - Country:US
Practice Address - Phone:773-769-4413
Practice Address - Fax:773-769-5140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL572210Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER