Basic Information
| Provider Information | |||||||||
| NPI: | 1619969748 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERGUSON | ||||||||
| FirstName: | MISTI | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 43RD AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612658401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097432070 | ||||||||
| FaxNumber: | 3097432073 | ||||||||
| Practice Location | |||||||||
| Address1: | 902 ILLINI DR | ||||||||
| Address2: | |||||||||
| City: | SILVIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612824700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097963450 | ||||||||
| FaxNumber: | 3097963460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 04/13/2012 | ||||||||
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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 | 225100000X | 070013897 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 03722 | IA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 070-013897 | 01 | IL | ILLINOIS PT LICENSE NO | OTHER | 1245373166 | 01 | IL | GROUP NPI NUMBER | OTHER |