Provider Demographics
NPI:1033117668
Name:ROSS, CHARLIE P (MD)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:P
Last Name:ROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CHARLIE
Other - Middle Name:PRICE
Other - Last Name:ROSS
Other - Suffix:III
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2911 MEDICAL ARTS ST
Mailing Address - Street 2:BLDG 2 ATTN: AUSTIN SURGICAL CLINIC ASSN
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-3376
Mailing Address - Country:US
Mailing Address - Phone:512-478-3402
Mailing Address - Fax:512-478-7114
Practice Address - Street 1:2911 MEDICAL ARTS ST
Practice Address - Street 2:BLDG 2 ATTN: AUSTIN SURGICAL CLINIC ASSN
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-3376
Practice Address - Country:US
Practice Address - Phone:512-478-3402
Practice Address - Fax:512-478-7114
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD4289208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C21333Medicare UPIN
TX805747Medicare ID - Type Unspecified