Healthcare Provider Details

I. General information

NPI: 1104881176
Provider Name (Legal Business Name): JONATHAN H ROSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 03/29/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST STE 710
CHICAGO IL
60612
US

IV. Provider business mailing address

1725 W HARRISON ST STE 710
CHICAGO IL
60612-3863
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-3034
  • Fax:
Mailing address:
  • Phone: 312-942-3034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number036-110209
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036-110209
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: