MEDICARE: ERIC J EROSS DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	3626	AZ
2	2084P0800X	Psychiatry Physician	3626	AZ
3	2084N0400X	Neurology Physician	3626	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3626	OTHER	AZ	LICENSE NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063574572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC J EROSS DO

Provider Business Mailing Address
First Line	:	4530 E MUIRWOOD DR STE 111
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85048-7693
Country	:	US
Telephone Number	:	480-961-2365
Fax Number	:	480-961-2382

Provider Business Practice Location Address
First Line	:	4530 E MUIRWOOD DR STE 111
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85048-7693
Country	:	US
Telephone Number	:	480-961-2365
Fax Number	:	480-961-2382

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	03/07/2023

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