Provider Demographics
NPI:1417942707
Name:ROSS, NATHANIEL T (MD)
Entity Type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:T
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:PO BOX 4787
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46404-0787
Mailing Address - Country:US
Mailing Address - Phone:219-886-4788
Mailing Address - Fax:219-886-4106
Practice Address - Street 1:1619 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46404-1506
Practice Address - Country:US
Practice Address - Phone:219-886-4788
Practice Address - Fax:219-886-4106
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052287207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA080179270OtherMEDICARE RAILROAD
IN200353510AMedicaid
GA080179270OtherMEDICARE RAILROAD
IN703730HMedicare PIN