Provider Demographics
NPI:1396341418
Name:INGRAM, KEVIN PAUL
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:PAUL
Last Name:INGRAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 MEDINA RD STE 300
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-5374
Mailing Address - Country:US
Mailing Address - Phone:330-596-1042
Mailing Address - Fax:614-515-5779
Practice Address - Street 1:1065 MEDINA RD
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-5375
Practice Address - Country:US
Practice Address - Phone:330-596-1042
Practice Address - Fax:614-515-5779
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-06
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator