Provider Demographics
NPI:1437153194
Name:INGRAM, THOMAS GLENN (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:GLENN
Last Name:INGRAM
Suffix:
Gender:M
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:PO BOX 6209
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42702-6209
Mailing Address - Country:US
Mailing Address - Phone:888-259-0031
Mailing Address - Fax:859-757-4501
Practice Address - Street 1:1111 CROWN POINTE DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-7101
Practice Address - Country:US
Practice Address - Phone:800-545-9031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28724207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64287246Medicaid
KYP00101625OtherRAILROAD MEDICARE
KYP00101625OtherRAILROAD MEDICARE
KY64287246Medicaid