=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841290129
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SCOTT A ROSS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2005
-----------------------------------------------------
Last Update Date | 11/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 62ND AVE N STE A
-----------------------------------------------------
City | MYRTLE BEACH
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29572-2957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-839-0957
-----------------------------------------------------
Fax | 843-839-0758
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 SINGLETON RIDGE RD ATTN PNS CREDENTIALING
-----------------------------------------------------
City | CONWAY
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29526-9142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-234-6946
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 0101053663
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 83593
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------