Provider Demographics
NPI:1053497453
Name:OLIVER, ROSS SAMUEL JR (MD)
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:SAMUEL
Last Name:OLIVER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2335 CHESTERFIELD AVENUE,
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1066
Mailing Address - Country:US
Mailing Address - Phone:304-344-3785
Mailing Address - Fax:304-344-3765
Practice Address - Street 1:2335 CHESTERFIELD AVENUE,
Practice Address - Street 2:SUITE 101
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1066
Practice Address - Country:US
Practice Address - Phone:304-344-3785
Practice Address - Fax:304-344-3765
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13925208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0216253040000OtherTRICARE
WV185112OtherSELECT NET
WV340002703OtherRAILROAD MC
WV001721031OtherBC BS
WV4242731OtherAETNA
WV0130039000Medicaid
WV1393063OtherMC UMW
WV1508836OtherCIGNA
WV1002718509OtherACORDIA PEIA
WV221960OtherCARELINK
WV0626881Medicare ID - Type Unspecified
WV0130039000Medicaid
D98066Medicare UPIN
WV0216253040000OtherTRICARE