Provider Demographics
NPI:1699783357
Name:FERGUSON, ERIC
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1895 KINGSLEY AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4466
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1895 KINGSLEY AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4466
Practice Address - Country:US
Practice Address - Phone:904-276-2549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1315462086S0127X, 2086S0127X
MI4301084651208600000X
PAMD4594832086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI06219OtherPARAMOUNT
MI4907831Medicaid
MI000000489362OtherANTHEM
OH2714978Medicaid
MI0204610872OtherBCBS MI
MI7349345OtherAETNA
MI39952OtherHPM
MIP00334569OtherRRMC
000000586986OtherANTHEM
MI157140OtherGLHP
MI143523OtherCARE CHOICE/PREFERRED CH
MI0204610872OtherBCBS MI
OH2714978Medicaid
OHFE4253031Medicare PIN
MI000000489362OtherANTHEM
MI157140OtherGLHP