Provider Demographics
NPI:1407888316
Name:ROSS, JOE R (MD)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:R
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 1:1421 N STATE ST
Mailing Address - Street 2:SUITE 403
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1658
Mailing Address - Country:US
Mailing Address - Phone:601-353-9900
Mailing Address - Fax:601-353-3654
Practice Address - Street 1:1421 N STATE ST
Practice Address - Street 2:SUITE 403
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1658
Practice Address - Country:US
Practice Address - Phone:601-353-9900
Practice Address - Fax:601-353-3654
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06768208800000X
TX53526E3603208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
340012772OtherMEDICARE RR
MS00115691Medicaid
MS00115691Medicaid
MSB30986Medicare UPIN
MS00115691Medicaid