MEDICARE: DR. STEPHANIE ANNE ROSS PH. D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01635161	OTHER	IL	BCBS ID NUMBER

General Provider Information

NPI Number	:	1043261951
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHANIE ANNE ROSS PH. D.

Provider Business Mailing Address
First Line	:	3633 W LAKE AVE
Second Line	:	SUITE 400
City	:	GLENVIEW
State	:	IL
Zip	:	60026-5805
Country	:	US
Telephone Number	:	773-459-6759
Fax Number	:	773-728-8719

Provider Business Practice Location Address
First Line	:	1000 CENTRAL ST
Second Line	:	SUITE 800
City	:	EVANSTON
State	:	IL
Zip	:	60201-1777
Country	:	US
Telephone Number	:	773-459-6756
Fax Number	:	773-728-8719

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2006
Last Update Date	:	07/09/2007

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