Provider Demographics
NPI:1639163397
Name:INGRAM, RUSSELL LEON (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:LEON
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 1:1460 2ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36265-3358
Mailing Address - Country:US
Mailing Address - Phone:256-435-2180
Mailing Address - Fax:256-435-9525
Practice Address - Street 1:1460 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AL
Practice Address - Zip Code:36265-3358
Practice Address - Country:US
Practice Address - Phone:256-435-2180
Practice Address - Fax:256-435-9525
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2007-07-26
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
AL7858207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51519662OtherBLUE CROSS BLUE SHIELD
AL051519662Medicaid
AL051519662Medicaid
AL51519662OtherBLUE CROSS BLUE SHIELD