Basic Information
| Provider Information | |||||||||
| NPI: | 1538170501 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | INGRAM | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | ONE MEDICAL CENTER BLVD | ||||||||
| Address2: | SUITE 231 | ||||||||
| City: | UPLAND | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106197475 | ||||||||
| FaxNumber: | 6106197477 | ||||||||
| Practice Location | |||||||||
| Address1: | ONE MEDICAL CENTER BLVD | ||||||||
| Address2: | SUITE 231 | ||||||||
| City: | UPLAND | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106197475 | ||||||||
| FaxNumber: | 6106197477 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 11/02/2012 | ||||||||
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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 | 207RG0100X | MD026652E | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 001345116 | 05 | CT | MEDICAID |