Provider Demographics
NPI:1881375657
Name:INGRAM, TOM AARON
Entity type:Individual
Prefix:
First Name:TOM
Middle Name:AARON
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 1:221 W HUBBARD ST UNIT 1708
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-4920
Mailing Address - Country:US
Mailing Address - Phone:706-580-0650
Mailing Address - Fax:
Practice Address - Street 1:1653 W CONGRESS PKWY # 12
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3833
Practice Address - Country:US
Practice Address - Phone:706-580-0650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-26
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209030865367500000X
AL1-174846163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered