Provider Demographics
NPI:1033381348
Name:DIANE E ROSS MD PA
Entity Type:Organization
Organization Name:DIANE E ROSS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-896-3317
Mailing Address - Street 1:2160 E PASS ROAD
Mailing Address - Street 2:SUITE D
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-3801
Mailing Address - Country:US
Mailing Address - Phone:228-896-3317
Mailing Address - Fax:228-896-3314
Practice Address - Street 1:2160 E PASS ROAD
Practice Address - Street 2:SUITE D
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3801
Practice Address - Country:US
Practice Address - Phone:228-896-3317
Practice Address - Fax:228-896-3314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS095622084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01121509Medicaid
MS130000002Medicare PIN
MSD00881Medicare UPIN