Basic Information
| Provider Information | |||||||||
| NPI: | 1295915759 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERGUSON | ||||||||
| FirstName: | JEFFERY | ||||||||
| MiddleName: | |||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 NORTHLAND BLVD FL 1 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452463604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136724128 | ||||||||
| FaxNumber: | 5136724479 | ||||||||
| Practice Location | |||||||||
| Address1: | 2139 AUBURN AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135850577 | ||||||||
| FaxNumber: | 5136724479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2007 | ||||||||
| LastUpdateDate: | 12/16/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/16/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 28188327A | IN | N | Nursing Service Providers | Registered Nurse | 367500000X | 28188327A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 287009 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | CERT #78435 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 000000947187 | 01 | IN | ANTHEM PROVIDER NUMBER | OTHER | 200914780 | 05 | IN | MEDICAID |