1194051623 NPI number — CHARLES ROSS MD PA

Table of content: (NPI 1194051623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194051623 NPI number — CHARLES ROSS MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARLES ROSS MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MEDEX WALK-IN
Provider Other Organization Name Type Code:
3
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:
1194051623
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1721 POWDER RIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALRICO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33594-4040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-389-7582
Provider Business Mailing Address Fax Number:
813-464-2781

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
511 W ALEXANDER ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
PLANT CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33563-7116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-719-7246
Provider Business Practice Location Address Fax Number:
813-464-2781
Provider Enumeration Date:
10/17/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ROSS
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
813-270-0325

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME96407 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1461Z . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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