MEDICARE: DR. JIM MARK INGRAM M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207K00000X	Allergy & Immunology Physician	C7708	AR

General Provider Information

NPI Number	:	1093707176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JIM MARK INGRAM M.D.

Provider Business Mailing Address
First Line	:	18 CORPORATE HILL DRIVE
Second Line	:	SUITE 110
City	:	LITTLE ROCK
State	:	AR
Zip	:	72205-4565
Country	:	US
Telephone Number	:	501-224-1156
Fax Number	:	501-801-5561

Provider Business Practice Location Address
First Line	:	18 CORPORATE HILL DR
Second Line	:	SUITE 110
City	:	LITTLE ROCK
State	:	AR
Zip	:	72205-4565
Country	:	US
Telephone Number	:	501-224-1156
Fax Number	:	501-801-5561

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2005
Last Update Date	:	07/08/2007

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