Provider Demographics
NPI:1467447755
Name:ROSS, RACHAEL L (MD)
Entity Type:Individual
Prefix:MS
First Name:RACHAEL
Middle Name:L
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 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:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057346A207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200504830AMedicaid
IN200504830AMedicaid
IN703730IMedicare ID - Type Unspecified