Provider Demographics
NPI:1679527949
Name:INGRAM, MICHAEL L (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
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 1:4143 CARMICHAEL RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-2803
Mailing Address - Country:US
Mailing Address - Phone:334-395-2200
Mailing Address - Fax:334-395-2290
Practice Address - Street 1:4143 CARMICHAEL RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2803
Practice Address - Country:US
Practice Address - Phone:334-395-2200
Practice Address - Fax:334-395-2290
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL218282085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009935667Medicaid
AL000077868Medicaid
AL009935668Medicaid
G82903Medicare UPIN
AL009935667Medicaid
000077868Medicare PIN
AL000077868Medicaid
4248810002Medicare NSC
4248810003Medicare NSC