Provider Demographics
NPI:1962811455
Name:INGRAM, JOHN M
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
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 1:1047 BURNS AVE
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:OH
Mailing Address - Zip Code:45215-2795
Mailing Address - Country:US
Mailing Address - Phone:513-462-8750
Mailing Address - Fax:
Practice Address - Street 1:1047 BURNS AVE
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:OH
Practice Address - Zip Code:45215-2795
Practice Address - Country:US
Practice Address - Phone:513-462-1194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-08
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0104731Medicaid