Provider Demographics
NPI:1073503660
Name:ROSS, MITCHELL K (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:K
Last Name:ROSS
Suffix:
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 1:10 MINOT AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210-4900
Mailing Address - Country:US
Mailing Address - Phone:207-795-2927
Mailing Address - Fax:207-795-2000
Practice Address - Street 1:10 MINOT AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-4900
Practice Address - Country:US
Practice Address - Phone:207-795-2927
Practice Address - Fax:207-795-2000
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME120922084N0400X
MEMD12092204R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432007500Medicaid
MEMM0516Medicare PIN