Healthcare Provider Details

I. General information

NPI: 1508869090
Provider Name (Legal Business Name): MARK J ROSS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

367 W EVANS ST
FLORENCE SC
29501-3429
US

IV. Provider business mailing address

367 W EVANS ST
FLORENCE SC
29501-3429
US

V. Phone/Fax

Practice location:
  • Phone: 843-669-4156
  • Fax: 843-664-2121
Mailing address:
  • Phone: 843-669-4156
  • Fax: 843-664-2121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number11764
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: