1831410703 NPI number — ROBERT NEAL INGRAM NP

Table of content: ROBERT NEAL INGRAM NP (NPI 1831410703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831410703 NPI number — ROBERT NEAL INGRAM NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
INGRAM
Provider First Name:
ROBERT
Provider Middle Name:
NEAL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831410703
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 N SHADELAND AVE STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46219-4959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1115 RONALD REAGAN PKWY
Provider Second Line Business Practice Location Address:
PKWY 171
Provider Business Practice Location Address City Name:
AVON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46123-6910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-278-3200
Provider Business Practice Location Address Fax Number:
317-273-5988
Provider Enumeration Date:
06/15/2010

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: 363LA2200X , with the licence number:  71003284A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163W00000X , with the licence number: 28161093A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 200988950 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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