Provider Demographics
NPI:1225738776
Name:INGRAM, SETH
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:
Last Name:INGRAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5760 PATRIOT BLVD.
Mailing Address - Street 2:
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-1170
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:NEWTON FALLS
Practice Address - State:OH
Practice Address - Zip Code:44444-1774
Practice Address - Country:US
Practice Address - Phone:330-501-2760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.003398175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAPS.00398Medicaid