Provider Demographics
NPI:1093711418
Name:ROSS, JEROME (MD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:
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 1:1001 PINE HEIGHTS AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-5208
Mailing Address - Country:US
Mailing Address - Phone:410-644-9515
Mailing Address - Fax:410-644-8250
Practice Address - Street 1:1001 PINE HEIGHTS AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-5208
Practice Address - Country:US
Practice Address - Phone:410-644-9515
Practice Address - Fax:410-644-8250
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0009835207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD36069OtherMAMSI
MD452862OtherAETNA
MD018041600Medicaid
MD5322-0001OtherBLUE CHOICE
MD36069OtherMAMSI
MDE00484Medicare UPIN
MD072L666AMedicare PIN