Basic Information
| Provider Information | |||||||||
| NPI: | 1245349414 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | INGRAM | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18341 US HIGHWAY 41 | ||||||||
| Address2: | |||||||||
| City: | LANSE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499468024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9065246118 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 18341 US HIGHWAY 41 | ||||||||
| Address2: | |||||||||
| City: | LANSE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499468024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9065246118 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 11/15/2012 | ||||||||
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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 | 207Q00000X | 4301053460 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 010Z76002 TI053460 | 01 | MI | BLUE CROSS - ER SERVICES | OTHER | 080065690 | 01 | RAILROAD MEDICARE - OFFIC | OTHER | 4627444 | 05 | MI | MEDICAID | 2990347 | 05 | MI | MEDICAID | 080065690 | 01 | RAILROAD MEDICARE- ER SER | OTHER | 080Z710040 TI053460 | 01 | MI | BLUE CROSS - OFFICE | OTHER | 238646 | 01 | MI | RHC MEDICARE | OTHER |