Provider Demographics
NPI:1760580013
Name:ROSS, MARY K (DPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:ROSS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:K
Other - Last Name:BLAKEMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:325 S 1ST AVE
Mailing Address - Street 2:PO BOX 435
Mailing Address - City:BROKEN BOW
Mailing Address - State:NE
Mailing Address - Zip Code:68822-2213
Mailing Address - Country:US
Mailing Address - Phone:308-872-5111
Mailing Address - Fax:308-872-5115
Practice Address - Street 1:325 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:NE
Practice Address - Zip Code:68822-2213
Practice Address - Country:US
Practice Address - Phone:308-872-5111
Practice Address - Fax:308-872-5115
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1511225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE39519OtherBLUE CROSS BLUE SHIELD
NE$$$$$$$$$00Medicaid
NE268277Medicare PIN