Provider Demographics
NPI:1952457525
Name:ICILMA V FERGUS, MD, PLLC
Entity Type:Organization
Organization Name:ICILMA V FERGUS, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ICILMA
Authorized Official - Middle Name:V
Authorized Official - Last Name:FERGUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-670-1234
Mailing Address - Street 1:4 WAGON WHEEL DR
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-1315
Mailing Address - Country:US
Mailing Address - Phone:718-670-1234
Mailing Address - Fax:718-661-7708
Practice Address - Street 1:5801 MAIN ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5333
Practice Address - Country:US
Practice Address - Phone:212-561-5792
Practice Address - Fax:347-923-9525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206086-1207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty