Organization Name: | MITZI FERGUSON, MD, LLC |
NPI Number: | 1952687717 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | SUSAN C. KERLEY (CREDENTIALING/BILLING SPECIALIST) |
Mailing Address: | 4500 I 55 N Suite 215 Jackson |
State: | MS US |
Postal Code: | 392115930 |
Phone Number: | 6012120955 |
Fax Number: | |
NPI Enumeration Date: | 10/25/2011 |
NPI Last Update Date: | 10/25/2011 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 208D00000X |
License Number: | 09298 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MS |
Taxonomy Type: | Allopathic & Osteopathic Physicians |
Taxonomy Classification: | General Practice |
Taxonomy Specialization: | |
Taxonomy Definition: |