Provider Demographics
NPI:1629072699
Name:INGRAM, RICHARD L (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
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 1:1602 VERNON RD
Mailing Address - Street 2:STE 400
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4100
Mailing Address - Country:US
Mailing Address - Phone:706-882-9341
Mailing Address - Fax:706-884-0131
Practice Address - Street 1:1602 VERNON RD
Practice Address - Street 2:STE 400
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4100
Practice Address - Country:US
Practice Address - Phone:706-882-9341
Practice Address - Fax:706-884-0131
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026563207RN0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00291024CMedicaid
GA00291024AMedicaid
GA$$$$$$$$$AMedicare PIN
GA00291024CMedicaid