Basic Information
| Provider Information | |||||||||
| NPI: | 1871761619 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | J KEVIN INGRAM MEDICAL, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14149 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708984149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889249827 | ||||||||
| FaxNumber: | 2259249829 | ||||||||
| Practice Location | |||||||||
| Address1: | 1806 CARTER ST | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 713733115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187576526 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2008 | ||||||||
| LastUpdateDate: | 06/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | INGRAM | ||||||||
| AuthorizedOfficialFirstName: | JOHNNY | ||||||||
| AuthorizedOfficialMiddleName: | KEVIN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3183368166 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD200671 | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1066435 | 05 | LA | MEDICAID |