Healthcare Provider Details

I. General information

NPI: 1497901854
Provider Name (Legal Business Name): AMANDA DAVIS INGRAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2008
Last Update Date: 10/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 W STONE DR
KINGSPORT TN
37660
US

IV. Provider business mailing address

3053 W STATE ST
BRISTOL TN
37620-1720
US

V. Phone/Fax

Practice location:
  • Phone: 423-968-1144
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number49584
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35098925
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: