MEDICARE: MICHAEL J INGERSOLL PSY.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	103TC0700X	Clinical Psychologist	071004707	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	680012120	OTHER	IL	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01618781	OTHER	IL	BC/BS

General Provider Information

NPI Number	:	1487630737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL J INGERSOLL PSY.D

Provider Business Mailing Address
First Line	:	PO BOX 713260
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60677-0018
Country	:	US
Telephone Number	:	630-469-9200
Fax Number	:

Provider Business Practice Location Address
First Line	:	640 S WASHINGTON ST
Second Line	:
City	:	NAPERVILLE
State	:	IL
Zip	:	60540-6603
Country	:	US
Telephone Number	:	815-942-6323
Fax Number	:	815-942-6363

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

Provider Enumeration Date	:	12/19/2005
Last Update Date	:	05/24/2023

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