Provider Demographics
NPI:1508870601
Name:ANTONSEN, INGRID C (MD)
Entity Type:Individual
Prefix:DR
First Name:INGRID
Middle Name:C
Last Name:ANTONSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 WINDSOR RD
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-6217
Mailing Address - Country:US
Mailing Address - Phone:217-366-6104
Mailing Address - Fax:
Practice Address - Street 1:1801 WINDSOR RD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-6217
Practice Address - Country:US
Practice Address - Phone:217-366-6104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-077650207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036077650-2Medicaid
IL279500OtherMEDICARE GROUP
IL080065701OtherRAILROAD MEDICARE
IL0407950001Medicare NSC
ILE49116Medicare UPIN
IL036077650-2Medicaid