Individual
RUSSELL LEON INGRAM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1460 2ND AVE SW, JACKSONVILLE, AL 36265-3358
(256) 435-2180
(256) 435-9525
Mailing address
1460 2ND AVE SW, JACKSONVILLE, AL 36265-3358
(256) 435-2180
(256) 435-9525
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
7858
AL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
051519662
—
AL
01
—
51519662
BLUE CROSS BLUE SHIELD
AL
Enumeration date
09/08/2005
Last updated
07/26/2007
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