Healthcare Provider Details

I. General information

NPI: 1386634715
Provider Name (Legal Business Name): GARY DEAN ROSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 04/03/2020
Certification Date: 04/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1464 JEFFERSON ST N
LEWISBURG WV
24901-1380
US

IV. Provider business mailing address

1464 JEFFERSON ST N
LEWISBURG WV
24901-1380
US

V. Phone/Fax

Practice location:
  • Phone: 304-645-3220
  • Fax: 844-479-4545
Mailing address:
  • Phone: 304-645-3220
  • Fax: 844-479-4545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number03051
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: