Provider Demographics
NPI:1992789507
Name:FERGUSON MEDICAL LABORATORIES INC
Entity type:Organization
Organization Name:FERGUSON MEDICAL LABORATORIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:HURLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-623-6330
Mailing Address - Street 1:PO BOX 20452
Mailing Address - Street 2:FML-CREDENTIALING
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-0452
Mailing Address - Country:US
Mailing Address - Phone:614-442-2406
Mailing Address - Fax:614-442-2410
Practice Address - Street 1:1801 W 32ND ST BLDG B
Practice Address - Street 2:SUITE 101
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1528
Practice Address - Country:US
Practice Address - Phone:417-623-6330
Practice Address - Fax:417-623-3950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207ZP0102X
MO26D0666300291U00000X
MO26D0445616291U00000X
MO26D0445668291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100410710AMedicaid
MO2182OtherBCBS
00002307OtherNHC HEALTH
183098OtherHEALTHLINK
CN6673OtherTRAVELERS
MOCN6673OtherRR MEDICARE
F21460OtherMERCY
MO690077013OtherRR MEDICARE
MO700432206Medicaid
MO=========2182OtherBLUE CHOICE
MO=========2182OtherBLUE CHOICE
MO700432206Medicaid
MO000010120Medicare PIN