Provider Demographics
NPI:1578694139
Name:JOHNNY SHANE ROSS INC
Entity Type:Organization
Organization Name:JOHNNY SHANE ROSS INC
Other - Org Name:JOHNNY SHANE ROSS, M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:GINGER
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-585-0180
Mailing Address - Street 1:2101 HEADWATER LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-7858
Mailing Address - Country:US
Mailing Address - Phone:580-585-0180
Mailing Address - Fax:
Practice Address - Street 1:2000 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-4200
Practice Address - Country:US
Practice Address - Phone:512-263-4511
Practice Address - Fax:512-263-4506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6036208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK613355600OtherDEPARTMENT OF LABOR
TX3445785 01Medicaid
TX3445785 01Medicaid
OK600522394Medicare Oscar/Certification