Basic Information
Provider Information | |||||||||
NPI: | 1841319068 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | INGRAM | ||||||||
FirstName: | CHRISTINA | ||||||||
MiddleName: | GUYTON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GUYTON | ||||||||
OtherFirstName: | CHRISTINA | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4055 LINDELL BLVD. | ||||||||
Address2: |   | ||||||||
City: | ST. LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631083201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3145357701 | ||||||||
FaxNumber: | 3145350207 | ||||||||
Practice Location | |||||||||
Address1: | 4055 LINDELL BLVD. | ||||||||
Address2: |   | ||||||||
City: | ST. LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631033201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3145357701 | ||||||||
FaxNumber: | 3145350207 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/28/2007 | ||||||||
LastUpdateDate: | 12/11/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 106585 | MO | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.