Provider Demographics
NPI:1982625802
Name:FERGUSON MEDICAL GROUP RURAL HEALTH CENTER INC
Entity Type:Organization
Organization Name:FERGUSON MEDICAL GROUP RURAL HEALTH CENTER INC
Other - Org Name:FERGUSON MEDICAL GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:SHILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-471-0330
Mailing Address - Street 1:PO BOX 1068
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-5044
Mailing Address - Country:US
Mailing Address - Phone:573-471-0330
Mailing Address - Fax:573-481-5019
Practice Address - Street 1:320 N LINCOLN ST
Practice Address - Street 2:
Practice Address - City:EAST PRAIRIE
Practice Address - State:MO
Practice Address - Zip Code:63845-1160
Practice Address - Country:US
Practice Address - Phone:573-649-3026
Practice Address - Fax:573-649-5600
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CICADA INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-23
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO595954116Medicaid
MO263930Medicare ID - Type UnspecifiedRH MC NUMBER