Healthcare Provider Details

I. General information

NPI: 1801933031
Provider Name (Legal Business Name): LOUIE GREG ROSS FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 HIGHWAY 49 S STE 4
RICHLAND MS
39218-9438
US

IV. Provider business mailing address

1220 N SHORE PKWY STE A
BRANDON MS
39047-6383
US

V. Phone/Fax

Practice location:
  • Phone: 601-932-6400
  • Fax: 601-664-0006
Mailing address:
  • Phone: 601-829-2939
  • Fax: 601-829-2995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR836293
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: