Healthcare Provider Details

I. General information

NPI: 1902488869
Provider Name (Legal Business Name): TAYLOR RAYE ROSS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2021
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 S NATIONAL AVE STE 610
SPRINGFIELD MO
65807-5209
US

IV. Provider business mailing address

1102 S PARK ST
MADISON WI
53715-1708
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-6000
  • Fax:
Mailing address:
  • Phone: 608-263-3111
  • Fax: 608-263-6663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2024036803
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: