Provider Demographics
NPI:1518921287
Name:ROSS, REX W (MD)
Entity Type:Individual
Prefix:
First Name:REX
Middle Name:W
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:#1 MEDICAL LANE
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-4912
Mailing Address - Country:US
Mailing Address - Phone:501-329-2948
Mailing Address - Fax:501-450-7243
Practice Address - Street 1:1 MEDICAL LN
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-4912
Practice Address - Country:US
Practice Address - Phone:501-329-2948
Practice Address - Fax:501-450-7243
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4639207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D04888Medicare UPIN
AR54553Medicare ID - Type Unspecified