Basic Information
| Provider Information | |||||||||
| NPI: | 1124009444 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERGUSON | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N ACADEMY AVE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178224903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702716144 | ||||||||
| FaxNumber: | 5702716578 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 N ACADEMY AVE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178221524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702717910 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 01/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0214X | 219101-1 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology | 2080P0214X | MD472414 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology |
ID Information
| ID | Type | State | Issuer | Description | 001397240 | 05 | CT | MEDICAID |