Healthcare Provider Details

I. General information

NPI: 1679952535
Provider Name (Legal Business Name): JORDAN B INGRAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 MATTHEW DR
WAYNESBORO MS
39367-2590
US

IV. Provider business mailing address

950 MATTHEW DR
WAYNESBORO MS
39367-2590
US

V. Phone/Fax

Practice location:
  • Phone: 601-735-5151
  • Fax: 601-735-7169
Mailing address:
  • Phone: 601-735-5151
  • Fax: 601-735-7169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number57323
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25095
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25095
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2023041851
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: