Provider Demographics
NPI:1093967259
Name:ROSS, PHILIP (PT)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:ROSS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2113 FOX TAIL CT
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-5043
Mailing Address - Country:US
Mailing Address - Phone:765-977-7138
Mailing Address - Fax:
Practice Address - Street 1:11401 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-1402
Practice Address - Country:US
Practice Address - Phone:904-260-1818
Practice Address - Fax:904-260-9733
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007001A225100000X
FLPT37332225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist