Healthcare Provider Details

I. General information

NPI: 1326044330
Provider Name (Legal Business Name): CHARLES B. ROSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 COLLIER ROAD SUITE 5015
ATLANTA GA
30309
US

IV. Provider business mailing address

95 COLLIER ROAD SUITE 5015
ATLANTA GA
30309
US

V. Phone/Fax

Practice location:
  • Phone: 404-605-5699
  • Fax: 404-355-4235
Mailing address:
  • Phone: 404-605-5699
  • Fax: 404-355-4235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number24250
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number01066838A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number068549
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: