MEDICARE: INGRAM HEALTH GROUP CO

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	207Q00000X	Family Medicine Physician	01043975A	IN

General Provider Information

NPI Number	:	1144536384
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INGRAM HEALTH GROUP CO

Provider Business Mailing Address
First Line	:	5868 E 71ST ST
Second Line	:	SUITE E-230
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-4075
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5868 E 71ST ST
Second Line	:	SUITE E-230
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-4075
Country	:	US
Telephone Number	:	317-480-2047
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JAMES INGRAM
Credential	:
Telephone Number	:	317-480-2047

Provider Enumeration Date	:	08/25/2010
Last Update Date	:	08/25/2010

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