Provider Demographics
NPI:1235346453
Name:ROSS, MICAELA (MD)
Entity Type:Individual
Prefix:
First Name:MICAELA
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
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:PO BOX 636324
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6324
Mailing Address - Country:US
Mailing Address - Phone:859-301-2018
Mailing Address - Fax:859-301-2073
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-301-2000
Practice Address - Fax:859-301-2073
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41791174400000X, 207ZP0101X, 207ZP0102X
OH35089779207ZP0101X
IN01065390A207ZP0102X, 207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No174400000XOther Service ProvidersSpecialist
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200931560Medicaid
KY7100038690Medicaid
OH2789648Medicaid
IN200931560Medicaid
KY0516613Medicare PIN
KY7100038690Medicaid
P00796193Medicare PIN