Basic Information
| Provider Information | |||||||||
| NPI: | 1972502706 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | INGRAM | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11109 PARKVIEW PLAZA DR # 117 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451701 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1314 E 7TH ST STE 103 | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467062533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609271982 | ||||||||
| FaxNumber: | 2609278380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 10/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01043975A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200130100 | 05 | IN | MEDICAID |