Basic Information
| Provider Information | |||||||||
| NPI: | 1457318768 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERGUSON | ||||||||
| FirstName: | VICTORIA | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5619-25 VINE STREET | ||||||||
| Address2: | SPECTRUM HEALTH SERVICES, INC. | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191391302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154712761 | ||||||||
| FaxNumber: | 2154712929 | ||||||||
| Practice Location | |||||||||
| Address1: | 1415 NORTH BROAD STREET | ||||||||
| Address2: | SUITE 224 BROAD STREET HEALTH CENTER | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191223323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152357944 | ||||||||
| FaxNumber: | 2152353361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 07/25/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | MW010066 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 101031434 | 05 | PA | MEDICAID |