Healthcare Provider Details

I. General information

NPI: 1295038354
Provider Name (Legal Business Name): KENNETH ROSS DO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2010
Last Update Date: 01/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 PONDER EXECUTIVE PLZ
HOUSE SPRINGS MO
63051-3431
US

IV. Provider business mailing address

4 PONDER EXECUTIVE PLZ
HOUSE SPRINGS MO
63051-3431
US

V. Phone/Fax

Practice location:
  • Phone: 636-671-1563
  • Fax: 636-671-3364
Mailing address:
  • Phone: 636-671-1563
  • Fax: 636-671-3364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR9C07
License Number StateMO

VIII. Authorized Official

Name: DR. KENNETH EARL ROSS
Title or Position: OWNER
Credential: DO
Phone: 636-671-1563