Provider Demographics
NPI:1942815394
Name:INGRAM, KRIS B
Entity Type:Individual
Prefix:
First Name:KRIS
Middle Name:B
Last Name:INGRAM
Suffix:
Gender:F
Credentials:
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 116
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:OH
Mailing Address - Zip Code:43112-0116
Mailing Address - Country:US
Mailing Address - Phone:740-215-7093
Mailing Address - Fax:
Practice Address - Street 1:52 S BEAVER ST
Practice Address - Street 2:
Practice Address - City:CARROLL
Practice Address - State:OH
Practice Address - Zip Code:43112-9002
Practice Address - Country:US
Practice Address - Phone:740-756-4058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-12
Last Update Date:2020-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0084066Medicaid