Provider Demographics
NPI:1487682977
Name:ROSS, JOSEPH E (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:E
Last Name:ROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1601 PARKVIEW AVENUE
Mailing Address - Street 2:CREDENTIALING S200C
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-2231
Mailing Address - Country:US
Mailing Address - Phone:815-395-5861
Mailing Address - Fax:815-395-5575
Practice Address - Street 1:1221 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2231
Practice Address - Country:US
Practice Address - Phone:815-972-1000
Practice Address - Fax:815-972-1086
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2023-11-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036060712207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036060712Medicaid
ILD14516Medicare UPIN
IL036060712Medicaid