=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750558003
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFFREY M ROSS, MD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2008
-----------------------------------------------------
Last Update Date | 11/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1670 CERRO GORDO RD
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87501-6175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-988-4349
-----------------------------------------------------
Fax | 505-989-7492
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1670 CERRO GORDO RD
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87501-6175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-988-4349
-----------------------------------------------------
Fax | 505-989-7492
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JEFFREY M. ROSS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 505-988-4349
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 87141
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------