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
State | License ID | Taxonomies |
---|---|---|
GA | 026563 | 207RN0300X, 207R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | |
No | 207RN0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
GA | 00291024C | Medicaid | |
GA | 00291024A | Medicaid | |
GA | $$$$$$$$$A | Medicare PIN | |
GA | 00291024C | Medicaid |