Provider Demographics
NPI:1326184029
Name:PRATTVILLE PRIMARY CARE LLC
Entity Type:Organization
Organization Name:PRATTVILLE PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:P
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-365-2205
Mailing Address - Street 1:PO DRAWER 681330
Mailing Address - Street 2:
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36068-1330
Mailing Address - Country:US
Mailing Address - Phone:334-365-2205
Mailing Address - Fax:334-361-7975
Practice Address - Street 1:461 E MAIN STREET
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36067
Practice Address - Country:US
Practice Address - Phone:334-365-2205
Practice Address - Fax:334-361-7975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10401207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000030008Medicaid
AL51030008OtherBLUE CROSS BLUE SHIELD
AL000030008Medicaid
C72396Medicare UPIN
ALH219Medicare PIN
=========OtherTRICARE