Provider Demographics
NPI:1285676031
Name:FERGUS FALLS MEDICAL GROUP, P.A.
Entity type:Organization
Organization Name:FERGUS FALLS MEDICAL GROUP, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-739-2221
Mailing Address - Street 1:615 S MILL ST
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2756
Mailing Address - Country:US
Mailing Address - Phone:218-739-2221
Mailing Address - Fax:218-739-5501
Practice Address - Street 1:615 S MILL ST
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2756
Practice Address - Country:US
Practice Address - Phone:218-739-2221
Practice Address - Fax:218-739-5501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN00-01587OtherFFMG MEDICA #
MN533810700Medicaid
MN62345FEOtherFFMG BCBS #
ND10344Medicaid
MN109516OtherFFMG UCARE #
ND10344Medicaid
MN62345FEOtherFFMG BCBS #
MN533810700Medicaid