Healthcare Provider Details

I. General information

NPI: 1811376494
Provider Name (Legal Business Name): JEREMY INGRAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2015
Last Update Date: 05/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1806 BONO RD APT 16
NEW ALBANY IN
47150-4680
US

IV. Provider business mailing address

1806 BONO RD APT 16
NEW ALBANY IN
47150-4680
US

V. Phone/Fax

Practice location:
  • Phone: 502-492-9928
  • Fax:
Mailing address:
  • Phone: 502-492-9928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: