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General NPI Number Information
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NPI Number | 1871761619
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Entity Type | Organization
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Legal Business Name | J KEVIN INGRAM MEDICAL, INC
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Dates
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Enumeration Date | 02/14/2008
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Last Update Date | 06/12/2008
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Provider Practice Location Address
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Address Line | 1806 CARTER ST
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City | VIDALIA
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State | LA
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Zip | 71373-3115
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Country | US
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Telephone | 318-757-6526
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 14149
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City | BATON ROUGE
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State | LA
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Zip | 70898-4149
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Country | US
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Telephone | 888-924-9827
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Fax | 225-924-9829
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Authorized Official
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Title or Position | OWNER
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Name | JOHNNY KEVIN INGRAM
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Credential | MD
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Telephone | 318-336-8166
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MD200671
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License Number State | LA
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