Provider Demographics
NPI:1659365872
Name:FERGUSON, EDRICK JORDAN (MD)
Entity type:Individual
Prefix:
First Name:EDRICK
Middle Name:JORDAN
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2444
Practice Address - Country:US
Practice Address - Phone:309-647-5240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350796932085R0202X
TN26307208D00000X
IL0361705092085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1508037Medicaid
OH000000270956OtherANTHEM
TN4191954OtherBLUE CROSS BLUE SHIELD
P00468253OtherRAILROAD MEDICARE
TN30885811Medicaid
OH2383924Medicaid
TN4166295OtherBCBS PROVIDER NUMBER
OH000000270956OtherANTHEM
TN4191954OtherBLUE CROSS BLUE SHIELD
F96295Medicare UPIN
TN1508037Medicaid