Provider Demographics
NPI:1891840641
Name:ROSS, ASHLEY EVAN
Entity Type:Individual
Prefix:DR
First Name:ASHLEY
Middle Name:EVAN
Last Name:ROSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 N SAINT CLAIR ST STE 20-150
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5979
Mailing Address - Country:US
Mailing Address - Phone:312-695-8146
Mailing Address - Fax:312-695-7030
Practice Address - Street 1:675 N SAINT CLAIR ST STE 20-150
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5979
Practice Address - Country:US
Practice Address - Phone:312-695-8146
Practice Address - Fax:312-695-7030
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD71523208800000X
IL036151981208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX368875601Medicaid
MD55783800Medicaid
TX368875602Medicaid
MD55783800Medicaid
TX368875601Medicaid
TX564655YM09Medicare PIN