1013367333 NPI number — DR. ROSS MICHAEL CANUP M.D.

Table of content: DR. ROSS MICHAEL CANUP M.D. (NPI 1013367333)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013367333 NPI number — DR. ROSS MICHAEL CANUP M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CANUP
Provider First Name:
ROSS
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1013367333
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
42D MEDICAL GROUP
Provider Second Line Business Mailing Address:
300 S. TWINING ST. BLDG 760
Provider Business Mailing Address City Name:
MAXWELL AFB
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36112-6027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-953-5200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
42D MEDICAL GROUP
Provider Second Line Business Practice Location Address:
300 S. TWINING ST. BLDG 760
Provider Business Practice Location Address City Name:
MAXWELL AFB
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36112-6027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-953-5200
Provider Business Practice Location Address Fax Number:
334-953-8607
Provider Enumeration Date:
06/17/2016

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: 207Q00000X , with the licence number:  0101263009 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0101263009 . This is a "VIRGINIA MEDICAL LICENSE" identifier . This identifiers is of the category "OTHER".




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