Provider Demographics
NPI:1245349414
Name:INGRAM, TODD V (MD)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:V
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 1:18341 US HIGHWAY 41
Mailing Address - Street 2:
Mailing Address - City:LANSE
Mailing Address - State:MI
Mailing Address - Zip Code:49946-8024
Mailing Address - Country:US
Mailing Address - Phone:906-524-6118
Mailing Address - Fax:
Practice Address - Street 1:18341 US HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:LANSE
Practice Address - State:MI
Practice Address - Zip Code:49946-8024
Practice Address - Country:US
Practice Address - Phone:906-524-6118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053460207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI010Z76002 TI053460OtherBLUE CROSS - ER SERVICES
080065690OtherRAILROAD MEDICARE - OFFIC
MI4627444Medicaid
MI2990347Medicaid
080065690OtherRAILROAD MEDICARE- ER SER
MI080Z710040 TI053460OtherBLUE CROSS - OFFICE
MI238646OtherRHC MEDICARE
0Z76002008Medicare ID - Type UnspecifiedER SERVICES
MI2990347Medicaid
F33247Medicare UPIN
MI0N95910Medicare PIN