Provider Demographics
NPI:1902043565
Name:MICHAEL ROSS SPORTS MEDICINE
Entity Type:Organization
Organization Name:MICHAEL ROSS SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JORDAN
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-952-6452
Mailing Address - Street 1:1159 MORRIS RD
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-2236
Mailing Address - Country:US
Mailing Address - Phone:610-952-6452
Mailing Address - Fax:484-412-8385
Practice Address - Street 1:1159 MORRIS RD
Practice Address - Street 2:
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096-2236
Practice Address - Country:US
Practice Address - Phone:610-952-6452
Practice Address - Fax:484-412-8385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-19
Last Update Date:2009-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD430033261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty