Healthcare Provider Details

I. General information

NPI: 1881375657
Provider Name (Legal Business Name): TOM AARON INGRAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2023
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1653 W CONGRESS PKWY # 12
CHICAGO IL
60612-3833
US

IV. Provider business mailing address

221 W HUBBARD ST UNIT 1708
CHICAGO IL
60654-4920
US

V. Phone/Fax

Practice location:
  • Phone: 706-580-0650
  • Fax:
Mailing address:
  • Phone: 706-580-0650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number1-174846
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209030865
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: