Provider Demographics
NPI:1437263662
Name:INGRASSIA, THEODORE S III (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:S
Last Name:INGRASSIA
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:535 ROXBURY RD
Mailing Address - Street 2:SUITE B600
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5076
Mailing Address - Country:US
Mailing Address - Phone:815-397-7212
Mailing Address - Fax:815-397-2539
Practice Address - Street 1:535 ROXBURY RD
Practice Address - Street 2:SUITE B600
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5076
Practice Address - Country:US
Practice Address - Phone:815-397-7212
Practice Address - Fax:815-397-2539
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036 083892207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL101 00686OtherBLUE CROSS BLUE SHIELD
IL036 083892Medicaid
IL110060997OtherRAILROAD MEDICARE
IL036 083892Medicaid
IL970580Medicare ID - Type Unspecified
ILK38184Medicare PIN