Provider Demographics
NPI:1972608982
Name:MOORMAN, ROSS GLENN III (MD)
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:GLENN
Last Name:MOORMAN
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ROSS
Other - Middle Name:GLENN
Other - Last Name:MOORMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2104 REDBIRD TRAIL
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533
Mailing Address - Country:US
Mailing Address - Phone:912-260-2287
Mailing Address - Fax:
Practice Address - Street 1:2104 REDBIRD TRAIL
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533
Practice Address - Country:US
Practice Address - Phone:912-260-2287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034668207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE93314Medicare UPIN