Healthcare Provider Details

I. General information

NPI: 1245291384
Provider Name (Legal Business Name): RUSSELL A ROSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 MOUNTAIN VIEW RD
WILLIAMSTON SC
29697-9601
US

IV. Provider business mailing address

520 MOUNTAIN VIEW RD
WILLIAMSTON SC
29697-9601
US

V. Phone/Fax

Practice location:
  • Phone: 864-225-0313
  • Fax:
Mailing address:
  • Phone: 864-225-0313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number19015
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19015
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: