Provider Demographics
NPI:1932102670
Name:ROSS, KERRY W (MD)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:W
Last Name:ROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 CRESTVIEW PARK DR
Mailing Address - Street 2:
Mailing Address - City:DICKSON
Mailing Address - State:TN
Mailing Address - Zip Code:37055-2850
Mailing Address - Country:US
Mailing Address - Phone:615-446-5121
Mailing Address - Fax:615-446-1357
Practice Address - Street 1:127 CRESTVIEW PARK DR
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-2850
Practice Address - Country:US
Practice Address - Phone:615-441-4472
Practice Address - Fax:615-441-4507
Is Sole Proprietor?:No
Enumeration Date:2005-05-26
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD32022208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
110236216OtherRAILROAD MEDICARE PIN
TN3877243Medicaid
TN4024935OtherBLUE CROSS BLUE SHIELD TN
110236216OtherRAILROAD MEDICARE PIN
TN3877243Medicaid