Provider Demographics
NPI:1023145224
Name:ROSS, STACY O (MD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:O
Last Name:ROSS
Suffix:
Gender:F
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:PO BOX 759047
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-9047
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:2855 CRAIN HWY
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-2807
Practice Address - Country:US
Practice Address - Phone:240-427-1926
Practice Address - Fax:240-427-1927
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD36924207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDE57433Medicare UPIN
MD627960YWV2Medicare PIN
MD190519YVZMedicare PIN
MD190519ZDDBMedicare PIN