Provider Demographics
NPI:1336139799
Name:INGRAM MEDICAL CLINIC-CARDIOVASCULAR DIVISION, LLC
Entity Type:Organization
Organization Name:INGRAM MEDICAL CLINIC-CARDIOVASCULAR DIVISION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:L
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-354-0552
Mailing Address - Street 1:415 BIENVILLE ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-5737
Mailing Address - Country:US
Mailing Address - Phone:318-354-0552
Mailing Address - Fax:318-354-2468
Practice Address - Street 1:501 KEYSER AVE
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-6018
Practice Address - Country:US
Practice Address - Phone:318-214-4550
Practice Address - Fax:318-354-2468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1993450Medicaid
LACH5188Medicare PIN
LA5DB66Medicare PIN