Healthcare Provider Details

I. General information

NPI: 1154699866
Provider Name (Legal Business Name): SHOMARI ROSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 COMER AVE
COLUMBUS GA
31904-8725
US

IV. Provider business mailing address

1803 INZERSS PARKWAY
COLUMBUS GA
31909
US

V. Phone/Fax

Practice location:
  • Phone: 706-323-0174
  • Fax: 706-256-3264
Mailing address:
  • Phone: 510-695-1043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: