Basic Information
| Provider Information | |||||||||
| NPI: | 1013265222 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERGUSON | ||||||||
| FirstName: | KESHIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 44004 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322314004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042021032 | ||||||||
| FaxNumber: | 9043485627 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 PRUDENTIAL DR STE 304 | ||||||||
| Address2: | CREDENTIALING DEPARTMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043463649 | ||||||||
| FaxNumber: | 9043485627 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2012 | ||||||||
| LastUpdateDate: | 12/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/16/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME 119816 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | Q9347 | TX | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 0136361-00 | 05 | FL | MEDICAID | P01389642 | 01 | FL | RAILROAD MEDICARE | OTHER |