Basic Information
| Provider Information | |||||||||
| NPI: | 1124068770 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | INGENITO | ||||||||
| FirstName: | ALLAN | ||||||||
| MiddleName: | PHILLIP | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3833 COON RAPIDS BLVD NW | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7634278320 | ||||||||
| FaxNumber: | 7633024338 | ||||||||
| Practice Location | |||||||||
| Address1: | 3833 COON RAPIDS BLVD NW | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7634278320 | ||||||||
| FaxNumber: | 7633024338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 03/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0402X | 29584 | MN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | 2084N0400X | 29584 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 07691IN | 01 | MN | BCBS OF MN | OTHER | 130005768 | 01 | MN | RAILROAD MEDICARE | OTHER | 162078900 | 05 | MN | MEDICAID | 30709400 | 01 | WI | WI MEDICAID | OTHER | 0265011 | 01 | MN | PREFERRED ONE | OTHER | HP13588 | 01 | MN | HEALTHPARTNERS | OTHER | 0509674 | 01 | MN | MEDICA | OTHER | 100289C029 | 01 | MN | UCARE | OTHER | 22676 | 01 | MN | AMERICA'S PPO | OTHER |