Provider Demographics
NPI:1346221231
Name:ROSS, MARVIN E (DO)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:E
Last Name:ROSS
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:1502 N JEFFERSON ST
Mailing Address - Street 2:JEFFERSON MEDICAL GROUP /ATTN: JEAN STEELE
Mailing Address - City:CARROLLTON
Mailing Address - State:MO
Mailing Address - Zip Code:64633-1948
Mailing Address - Country:US
Mailing Address - Phone:660-542-9998
Mailing Address - Fax:660-542-9880
Practice Address - Street 1:1502 N JEFFERSON ST
Practice Address - Street 2:JEFFERSON MEDICAL GROUP /ATTN: JEAN STEELE
Practice Address - City:CARROLLTON
Practice Address - State:MO
Practice Address - Zip Code:64633-1948
Practice Address - Country:US
Practice Address - Phone:660-542-9998
Practice Address - Fax:660-542-9880
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR6529207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO240555300Medicaid
MO240555300Medicaid
MO0003459Medicare PIN