1053594697 NPI number — TIMOTHY T ROSS MD

Table of content: (NPI 1053594697)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053594697 NPI number — TIMOTHY T ROSS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIMOTHY T ROSS MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053594697
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11500 NE 76TH ST STE A3
Provider Second Line Business Mailing Address:
PMB 7
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98662-3901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-254-3663
Provider Business Mailing Address Fax Number:
360-254-3719

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
715 S ANDRESEN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98661-7603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-693-7877
Provider Business Practice Location Address Fax Number:
360-750-6900
Provider Enumeration Date:
12/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROSS
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
TODD
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
360-254-3663

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  MD00019932 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 314000000X , with the licence number: MD12417 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7034572 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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