Provider Demographics
NPI:1326198367
Name:INGALLS FAMILY MEDICINE CLINIC SC
Entity Type:Organization
Organization Name:INGALLS FAMILY MEDICINE CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:INGALLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:715-866-4271
Mailing Address - Street 1:7456 MAIN ST W
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:WI
Mailing Address - Zip Code:54893-8205
Mailing Address - Country:US
Mailing Address - Phone:715-866-4271
Mailing Address - Fax:715-866-4284
Practice Address - Street 1:7456 MAIN ST W
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:WI
Practice Address - Zip Code:54893-8205
Practice Address - Country:US
Practice Address - Phone:715-866-4271
Practice Address - Fax:715-866-4284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31328207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21250000Medicaid
WI21250000Medicaid