1396853396 NPI number — MICHAEL ROSS PA

Table of content: MICHAEL ROSS PA (NPI 1396853396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396853396 NPI number — MICHAEL ROSS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSS
Provider First Name:
MICHAEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1396853396
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 22000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANGELO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76902-7200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-942-8611
Provider Business Mailing Address Fax Number:
325-481-2165

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3502 KNICKERBOCKER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANGELO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76904-7671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-942-8611
Provider Business Practice Location Address Fax Number:
325-659-0180
Provider Enumeration Date:
08/29/2006

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: 363A00000X , with the licence number:  PA04079 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 189528605 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 189528607 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 189528606 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 189528608 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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