Provider Demographics
NPI:1528564838
Name:LAURENT, ROSS A (MD)
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:A
Last Name:LAURENT
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 735041
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5041
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-4060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI73061207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100078600Medicaid