Provider Demographics
NPI:1700822558
Name:INGERSOLL, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:INGERSOLL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S PRESTON ST # B
Mailing Address - Street 2:
Mailing Address - City:RANSON
Mailing Address - State:WV
Mailing Address - Zip Code:25438-1628
Mailing Address - Country:US
Mailing Address - Phone:304-725-7884
Mailing Address - Fax:304-725-5913
Practice Address - Street 1:201 S PRESTON ST # B
Practice Address - Street 2:
Practice Address - City:RANSON
Practice Address - State:WV
Practice Address - Zip Code:25438-1628
Practice Address - Country:US
Practice Address - Phone:304-725-7884
Practice Address - Fax:304-725-5913
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
WV17231207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001721515OtherBLUE CROSS/BLUE SHIELD WV
WV0097825000Medicaid
WVF52014Medicare UPIN
WV0097825000Medicaid