Provider Demographics
NPI:1043298037
Name:INGRAHAM, ALLAN M (MD)
Entity Type:Individual
Prefix:
First Name:ALLAN
Middle Name:M
Last Name:INGRAHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 SHEPLEY ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210
Mailing Address - Country:US
Mailing Address - Phone:207-784-4722
Mailing Address - Fax:
Practice Address - Street 1:60 HIGH ST
Practice Address - Street 2:CMHVI-Y1
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240
Practice Address - Country:US
Practice Address - Phone:207-795-8260
Practice Address - Fax:207-795-8281
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME9007208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME110030000Medicaid
167452Medicare ID - Type Unspecified
B86809Medicare UPIN
ME110030000Medicaid