Individual
EDRICK JORDAN FERGUSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
210 W WALNUT ST, CANTON, IL 61520-2444
(309) 647-5240
Mailing address
611 W PARK ST, URBANA, IL 61801-2500
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
036170509
IL
2085R0202X
Diagnostic Radiology Physician
35079693
OH
208D00000X
General Practice Physician
26307
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000270956
ANTHEM
OH
05
—
1508037
—
TN
05
—
2383924
—
OH
05
—
30885811
—
TN
01
—
4166295
BCBS PROVIDER NUMBER
TN
01
—
4191954
BLUE CROSS BLUE SHIELD
TN
01
—
P00468253
RAILROAD MEDICARE
—
Enumeration date
09/02/2005
Last updated
12/23/2024
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