Provider Demographics
NPI:1639130099
Name:ROSS, GARY MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:MICHAEL
Last Name:ROSS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-2322
Mailing Address - Country:US
Mailing Address - Phone:207-989-5588
Mailing Address - Fax:207-989-1599
Practice Address - Street 1:401 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412-2322
Practice Address - Country:US
Practice Address - Phone:207-989-5588
Practice Address - Fax:207-989-1599
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEME1127208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME297030099Medicaid
ME297030099Medicaid
MEMM0533Medicare ID - Type Unspecified