Provider Demographics
NPI:1861758526
Name:FERGUSON, KEITH TIMOTHY (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:TIMOTHY
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3635 VISTA AVE FL 7
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2539
Mailing Address - Country:US
Mailing Address - Phone:314-577-8856
Mailing Address - Fax:314-577-8859
Practice Address - Street 1:3660 VISTA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2540
Practice Address - Country:US
Practice Address - Phone:314-977-6100
Practice Address - Fax:314-977-6164
Is Sole Proprietor?:No
Enumeration Date:2012-04-06
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI61842-20207RC0200X, 207RP1001X
IL036140072207RC0200X, 207RP1001X
MO2020013186207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1861758526Medicaid