Provider Demographics
NPI:1588618474
Name:INGRAM, CHARLES C (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:C
Last Name:INGRAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6060 PRIMACY PKWY
Mailing Address - Street 2:SUITE 241
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5745
Mailing Address - Country:US
Mailing Address - Phone:901-725-5846
Mailing Address - Fax:
Practice Address - Street 1:1265 UNION AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3415
Practice Address - Country:US
Practice Address - Phone:901-725-5846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30064207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3091897OtherBLUECROSS BLUESHIELD
AR97920OtherBLUECROSS BLUESHIELD
TN3825084Medicaid
MS00120711Medicaid
AR140245001Medicaid
MO205095300Medicaid
50065532OtherMEDICARE RAILROAD
MO205095300Medicaid