Provider Demographics
NPI:1881259604
Name:INGRAM, ISAIAH CHARLES
Entity type:Individual
Prefix:
First Name:ISAIAH
Middle Name:CHARLES
Last Name:INGRAM
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 1:705 RILEY HOSPITAL DR., RI-5837
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202
Mailing Address - Country:US
Mailing Address - Phone:317-944-4034
Mailing Address - Fax:
Practice Address - Street 1:705 RILEY HOSPITAL DR., RI-5837
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202
Practice Address - Country:US
Practice Address - Phone:317-944-4034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-07
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program