Provider Demographics
NPI:1467452987
Name:INGRAM, ALISA D (MD)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:D
Last Name:INGRAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:501 VAN BUREN ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:FOSTORIA
Mailing Address - State:OH
Mailing Address - Zip Code:44830-1593
Mailing Address - Country:US
Mailing Address - Phone:419-436-1035
Mailing Address - Fax:419-435-0849
Practice Address - Street 1:501 VAN BUREN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:FOSTORIA
Practice Address - State:OH
Practice Address - Zip Code:44830-1593
Practice Address - Country:US
Practice Address - Phone:419-436-1035
Practice Address - Fax:419-435-0849
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35082217207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH04357OtherPARAMOUNT
OH23-54980OtherUHC
OH000000348462OtherANTHEM
OH2408933Medicaid
OH7871493OtherAETNA
OHP00061267OtherRRMC
OHP00061267OtherRRMC
OHH92840Medicare UPIN