Provider Demographics
NPI:1578531406
Name:ROSS, ALAN D M (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:D M
Last Name:ROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-4100
Mailing Address - Country:US
Mailing Address - Phone:207-623-6355
Mailing Address - Fax:207-622-0853
Practice Address - Street 1:147 RIVERSIDE DR
Practice Address - Street 2:STE 1
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-4100
Practice Address - Country:US
Practice Address - Phone:207-623-6355
Practice Address - Fax:207-622-0853
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ME014778208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME131670000Medicaid
MEMM7322Medicare ID - Type Unspecified
ME131670000Medicaid