Provider Demographics
NPI:1740235878
Name:INGRAM, KEITH E (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:E
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:PO BOX 1106
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-1106
Mailing Address - Country:US
Mailing Address - Phone:772-219-9005
Mailing Address - Fax:
Practice Address - Street 1:6830 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-1410
Practice Address - Country:US
Practice Address - Phone:772-873-6700
Practice Address - Fax:772-465-5499
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME46955207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL08630OtherBLUE CROSS BLUE SHIELD
P00614586OtherMEDICARE RAILROAD
FL007276900Medicaid
P00614586OtherMEDICARE RAILROAD
FLE22563Medicare UPIN