Provider Demographics
NPI:1902839483
Name:BRIDGE, ROSS EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:EDWARD
Last Name:BRIDGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3917 WEST RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-2275
Mailing Address - Country:US
Mailing Address - Phone:505-662-4351
Mailing Address - Fax:505-662-2932
Practice Address - Street 1:3917 WEST RD
Practice Address - Street 2:SUITE 150
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-2275
Practice Address - Country:US
Practice Address - Phone:505-662-4351
Practice Address - Fax:505-662-2932
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2010-10-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI44252207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34010900Medicaid
G56184Medicare UPIN
WI34010900Medicaid