Healthcare Provider Details

I. General information

NPI: 1578537296
Provider Name (Legal Business Name): ROSS W BUCKLES DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 12/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2214 CANTERBURY DR SUITE 204
HAYS KS
67601-2375
US

IV. Provider business mailing address

2214 CANTERBURY DR SUITE 204
HAYS KS
67601-2375
US

V. Phone/Fax

Practice location:
  • Phone: 785-623-2360
  • Fax: 785-623-2371
Mailing address:
  • Phone: 785-623-2360
  • Fax: 785-623-2371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number05-30122
License Number StateKS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100454950A
Identifier TypeMEDICAID
Identifier StateKS
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: