Provider Demographics
NPI:1578567251
Name:ROSS, JOHN RICHARD SR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RICHARD
Last Name:ROSS
Suffix:SR
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 1:795 COOK RD
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-2127
Mailing Address - Country:US
Mailing Address - Phone:803-533-7544
Mailing Address - Fax:803-533-7545
Practice Address - Street 1:3000 SAINT MATTHEWS RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-1442
Practice Address - Country:US
Practice Address - Phone:803-395-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2023-06-08
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-20
Provider Licenses
StateLicense IDTaxonomies
SC7709208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC077099Medicaid
SC7399OtherMEDICARE GROUP PTAN
SCD18168Medicare UPIN
SCD181682045Medicare PIN