Provider Demographics
NPI:1134553019
Name:KIM M ROSS MD
Entity type:Organization
Organization Name:KIM M ROSS MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-225-2769
Mailing Address - Street 1:1303 MCCULLOUGH AVE STE 560
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-5607
Mailing Address - Country:US
Mailing Address - Phone:210-225-2769
Mailing Address - Fax:210-222-9275
Practice Address - Street 1:1303 MCCULLOUGH AVE STE 560
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212
Practice Address - Country:US
Practice Address - Phone:210-225-2769
Practice Address - Fax:210-222-9275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6276207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113449601Medicaid
TX00973LMedicare PIN
TX113449601Medicaid
TXG71966Medicare UPIN