Provider Demographics
NPI:1366420614
Name:FERGUSON, ANGELA BETH (MD)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:BETH
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301-6 GREAT TEAYS BLVD
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560
Mailing Address - Country:US
Mailing Address - Phone:304-757-6999
Mailing Address - Fax:304-757-3252
Practice Address - Street 1:301-6 GREAT TEAYS BLVD
Practice Address - Street 2:
Practice Address - City:SCOTT DEPOT
Practice Address - State:WV
Practice Address - Zip Code:25560
Practice Address - Country:US
Practice Address - Phone:304-757-6999
Practice Address - Fax:304-757-3252
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20603208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7623269OtherAETNA
WV1807628000Medicaid
WV001721959OtherMS BCBS
WV1807628000Medicaid
H49165Medicare UPIN
WV4060592Medicare PIN
WV7623269OtherAETNA