Basic Information
| Provider Information | |||||||||
| NPI: | 1659395390 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERGUSON | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 71 ALLEN ST | ||||||||
| Address2: | STE 403 | ||||||||
| City: | RUTLAND | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057014570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027724414 | ||||||||
| FaxNumber: | 8027727973 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 GENERAL WING RD | ||||||||
| Address2: | CHCRR PEDIATRICS | ||||||||
| City: | RUTLAND | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057014681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027739131 | ||||||||
| FaxNumber: | 8027731551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 08/26/2016 | ||||||||
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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 | 208000000X | 042-0009717 | VT | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 30200039 | 05 | NH | MEDICAID | 04312281 | 05 | NY | MEDICAID | 1006417 | 05 | VT | MEDICAID |