Basic Information
| Provider Information | |||||||||
| NPI: | 1851357891 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANKSTON | ||||||||
| FirstName: | INGRUM | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 AFFLINK PL STE 101 | ||||||||
| Address2: | |||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354062452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053669740 | ||||||||
| FaxNumber: | 2053449992 | ||||||||
| Practice Location | |||||||||
| Address1: | 1780 MCFARLAND BLVD N | ||||||||
| Address2: | |||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354062136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053457351 | ||||||||
| FaxNumber: | 2053458476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 01/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 9502 | AL | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 114341 | 05 | AL | MEDICAID | 51067817 | 01 | AL | BCBS OF ALABAMA | OTHER |