Provider Demographics
NPI:1851517999
Name:INGALLS, JERRELL (MD)
Entity Type:Individual
Prefix:
First Name:JERRELL
Middle Name:
Last Name:INGALLS
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 1:445 HARLOW RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-1341
Mailing Address - Country:US
Mailing Address - Phone:541-302-7771
Mailing Address - Fax:
Practice Address - Street 1:445 HARLOW RD STE 200
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-1341
Practice Address - Country:US
Practice Address - Phone:541-302-7771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010836592085R0202X
OH35.0930432085R0202X
KY436632085R0202X
NV138572085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1851517999Medicaid
OK200469660AMedicaid
NVP01168760OtherRR MEDICARE
NV1851517999Medicaid
AZ624266Medicaid
NVFE246YMedicare PIN
NV1851517999Medicaid
NVFE246ZMedicare PIN
AZ624266Medicaid