Healthcare Provider Details

I. General information

NPI: 1760941868
Provider Name (Legal Business Name): SAMUEL WARREN ROSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 FRANKLIN AVE
GARDEN CITY NY
11530-1617
US

IV. Provider business mailing address

700 HICKSVILLE RD STE 205
BETHPAGE NY
11714-3472
US

V. Phone/Fax

Practice location:
  • Phone: 516-663-4600
  • Fax: 516-663-3008
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number317200
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: