Provider Demographics
NPI:1730276890
Name:FAMILY TREE OB GYN, PA
Entity type:Organization
Organization Name:FAMILY TREE OB GYN, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:VAUGHN
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-342-6063
Mailing Address - Street 1:520 MAPLE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-4652
Mailing Address - Country:US
Mailing Address - Phone:336-342-6063
Mailing Address - Fax:336-342-7847
Practice Address - Street 1:520 MAPLE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-4652
Practice Address - Country:US
Practice Address - Phone:336-342-6063
Practice Address - Fax:336-342-7847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26070174400000X
207V00000X, 363LA2200X, 363LG0600X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Not Answered207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Not Answered363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Not Answered363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty
Not Answered367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89012KHMedicaid
NC012KHOtherBCBS
NC89012KHMedicaid