Healthcare Provider Details

I. General information

NPI: 1629072699
Provider Name (Legal Business Name): RICHARD L INGRAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 09/29/2026
Certification Date: 04/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 VERNON RD STE 400
LAGRANGE GA
30240-4100
US

IV. Provider business mailing address

1602 VERNON RD STE 400
LAGRANGE GA
30240-4100
US

V. Phone/Fax

Practice location:
  • Phone: 706-882-9341
  • Fax: 706-884-0131
Mailing address:
  • Phone: 706-882-9341
  • Fax: 706-884-0131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number026563
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number026563
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: