Healthcare Provider Details

I. General information

NPI: 1083982243
Provider Name (Legal Business Name): BRENDA ROSS MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2011
Last Update Date: 12/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13851 HIGHWAY 28
WHITWELL TN
37397-5373
US

IV. Provider business mailing address

13851 HIGHWAY 28
WHITWELL TN
37397-5373
US

V. Phone/Fax

Practice location:
  • Phone: 423-658-9200
  • Fax: 423-658-2195
Mailing address:
  • Phone: 423-658-9200
  • Fax: 423-658-2195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD0000025147
License Number StateTN

VIII. Authorized Official

Name: DR. BRENDA ROSS
Title or Position: OWNER
Credential: MD
Phone: 423-658-9200