Provider Demographics
NPI:1235357104
Name:INGALLS, NICHOLE (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:INGALLS
Suffix:
Gender:F
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:PEACEHEALTH SURGICAL SPECIALTIES
Mailing Address - Street 2:3355 RIVERBEND DR STE 300
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-8800
Mailing Address - Country:US
Mailing Address - Phone:541-222-8333
Mailing Address - Fax:541-222-8320
Practice Address - Street 1:PEACEHEALTH SURGICAL SPECIALTIES
Practice Address - Street 2:3355 RIVERBEND DR STE 300
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-8800
Practice Address - Country:US
Practice Address - Phone:541-222-8333
Practice Address - Fax:541-222-8320
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1713812086S0102X, 208600000X
MI4301083476208600000X
OH35.0934242086S0102X
NV138802086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500688597Medicaid
OH2979899Medicaid
IN200961730Medicaid
OR500688597Medicaid
IN200961730Medicaid
OHIN4264931Medicare PIN
ORR181761Medicare PIN