Provider Demographics
NPI:1578507133
Name:ROSS, JEFFREY D (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:D
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 1:200 CORPORATE BLVD.
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:427 HWY 51 NORTH
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2600
Practice Address - Country:US
Practice Address - Phone:601-833-0541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11415207P00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS4270448312BOtherBLUE CROSS
MS00124738Medicaid
MSMS11415MOtherMS STATE LICENSE
MS4270448312BOtherBLUE CROSS
MSD80579Medicare UPIN
MS930003285Medicare ID - Type Unspecified
MS050089300Medicare ID - Type UnspecifiedMEDICARE RAILROAD ID