Healthcare Provider Details

I. General information

NPI: 1053384818
Provider Name (Legal Business Name): KELLY L. ROSS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 SOUTH 65 HIGHWAY
MARSHALL MO
65340-3702
US

IV. Provider business mailing address

2305 SOUTH 65 HIGHWAY
MARSHALL MO
65340-3702
US

V. Phone/Fax

Practice location:
  • Phone: 660-886-8414
  • Fax: 660-831-3325
Mailing address:
  • Phone: 660-831-3553
  • Fax: 660-831-3325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number2005023176
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: