1073044038 NPI number — AMANDA RAE INGRAM M.D.

Table of content: JESSICA PHILLIPS OTA (NPI 1952176901)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073044038 NPI number — AMANDA RAE INGRAM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
INGRAM
Provider First Name:
AMANDA
Provider Middle Name:
RAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HARRELL
Provider Other First Name:
AMANDA
Provider Other Middle Name:
R.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1073044038
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 68
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POLLOCKSVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28573-0068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-633-2712
Provider Business Mailing Address Fax Number:
252-633-5418

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
705 NEWMAN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW BERN
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28562-5239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-633-2712
Provider Business Practice Location Address Fax Number:
252-633-5418
Provider Enumeration Date:
03/22/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: 2022-01723 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)