Provider Demographics
NPI:1649202946
Name:S DAVID ROSS II SC
Entity Type:Organization
Organization Name:S DAVID ROSS II SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:S
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-726-8820
Mailing Address - Street 1:2524 FARRAGUT DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-8400
Mailing Address - Country:US
Mailing Address - Phone:217-726-8820
Mailing Address - Fax:217-726-6796
Practice Address - Street 1:2524 FARRAGUT DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-8400
Practice Address - Country:US
Practice Address - Phone:217-726-8820
Practice Address - Fax:217-726-6796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036041875207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036041875Medicaid
IL205834Medicare ID - Type Unspecified
IL036041875Medicaid