Provider Demographics
NPI:1124153986
Name:JOHN D FERRIS PC
Entity type:Organization
Organization Name:JOHN D FERRIS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:FERRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-856-0009
Mailing Address - Street 1:300 N BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-3545
Mailing Address - Country:US
Mailing Address - Phone:307-856-0009
Mailing Address - Fax:
Practice Address - Street 1:300 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-3545
Practice Address - Country:US
Practice Address - Phone:307-856-0009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2139A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY010062665OtherRAILROAD MEDICARE
WY108971400Medicaid
CO89334841Medicaid
KS0000563350OtherBC BS OF KS
CO91021394Medicaid
KS0000563350OtherBC BS OF KS
WY010062665OtherRAILROAD MEDICARE
WYD24749Medicare UPIN
COC29281Medicare ID - Type Unspecified
WY=========OtherEIN