Provider Demographics
NPI:1477527075
Name:INGLE, MARY TEAGUE (PA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:TEAGUE
Last Name:INGLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3485 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:AL
Mailing Address - Zip Code:35209-5603
Mailing Address - Country:US
Mailing Address - Phone:205-930-0920
Mailing Address - Fax:205-445-0143
Practice Address - Street 1:3485 INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:AL
Practice Address - Zip Code:35209-5603
Practice Address - Country:US
Practice Address - Phone:205-930-0920
Practice Address - Fax:205-445-0143
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA339363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL0366100001OtherCIGNA GOVERNMENT SERVICES PTAN
AL0366100001OtherMC NSC
ALP99440OtherHEALTH SPRINGS
AL009940606Medicaid
AL000001591Medicare ID - Type Unspecified
AL009940606Medicaid