Healthcare Provider Details

I. General information

NPI: 1588779904
Provider Name (Legal Business Name): BRANDI KATHRYN ROSS-DOUGLAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8701 BROADWAY
MERRILLVILLE IN
46410-7035
US

IV. Provider business mailing address

601 E ROLLINS ST
ORLANDO FL
32803-1248
US

V. Phone/Fax

Practice location:
  • Phone: 219-738-3424
  • Fax:
Mailing address:
  • Phone: 407-303-7283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME125974
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036-115410
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number55363-20
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number4301102000
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number01065198
License Number StateIN
# 6
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberC146751
License Number StateCA
# 7
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberME125974
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: