Basic Information
| Provider Information | |||||||||
| NPI: | 1770516684 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERGUSON | ||||||||
| FirstName: | VINCENT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 532723 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303532723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048051300 | ||||||||
| FaxNumber: | 9048051302 | ||||||||
| Practice Location | |||||||||
| Address1: | 138 W GIBSON ST | ||||||||
| Address2: | |||||||||
| City: | HARTWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306431847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048051300 | ||||||||
| FaxNumber: | 9048051302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 37203 | GA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 007073 | 01 | GA | BLUE CROSS | OTHER | G37203 | 05 | SC | MEDICAID |