Healthcare Provider Details

I. General information

NPI: 1396754073
Provider Name (Legal Business Name): NATHANIEL ROSS MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8701 BROADWAY
MERRILLVILLE IN
46410-7035
US

IV. Provider business mailing address

55 E 86TH AVE PO BOX 10645
MERRILLVILLE IN
46410-6382
US

V. Phone/Fax

Practice location:
  • Phone: 219-769-1670
  • Fax: 219-738-6714
Mailing address:
  • Phone: 219-769-1670
  • Fax: 219-738-6714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01052287
License Number StateIN

VIII. Authorized Official

Name: NATHANIEL ROSS
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 219-769-1670