Healthcare Provider Details

I. General information

NPI: 1023058906
Provider Name (Legal Business Name): CHARLES THOMAS INGRAM JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1077 S MAIN
MADISON GA
30650
US

IV. Provider business mailing address

PO BOX 72483
MARIETTA GA
30007-2483
US

V. Phone/Fax

Practice location:
  • Phone: 706-342-1667
  • Fax:
Mailing address:
  • Phone: 770-578-1800
  • Fax: 770-578-6168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number19704
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: