Provider Demographics
NPI:1568576734
Name:THEODORE S. INGRASSIA, III, M.D.S.C.
Entity Type:Organization
Organization Name:THEODORE S. INGRASSIA, III, M.D.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:S
Authorized Official - Last Name:INGRASSIA
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:815-397-7212
Mailing Address - Street 1:5668 E STATE ST
Mailing Address - Street 2:SUITE B600
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2490
Mailing Address - Country:US
Mailing Address - Phone:815-397-7212
Mailing Address - Fax:815-397-2539
Practice Address - Street 1:5668 E STATE ST
Practice Address - Street 2:SUITE B600
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2490
Practice Address - Country:US
Practice Address - Phone:815-397-7212
Practice Address - Fax:815-397-2539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL101 00686OtherBLUE CROSS BLUE SHIELD
IL970580Medicare ID - Type Unspecified
ILF20691Medicare UPIN