Provider Demographics
NPI:1295178614
Name:ROSS, PHILLIP RANDALL (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:RANDALL
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 1:234 GOODMAN ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2364
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7690 DISCOVERY DR
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-6542
Practice Address - Country:US
Practice Address - Phone:513-475-8690
Practice Address - Fax:513-475-8629
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-16
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.137015207X00000X
390200000X
MI4301114341390200000X
OH35137015207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program