Provider Demographics
NPI:1205871464
Name:ROSS, PHILLIP SCOTT (PT)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:SCOTT
Last Name:ROSS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RED BOILING SPRINGS
Mailing Address - State:TN
Mailing Address - Zip Code:37150-2149
Mailing Address - Country:US
Mailing Address - Phone:270-255-1192
Mailing Address - Fax:
Practice Address - Street 1:309 MAIN ST
Practice Address - Street 2:
Practice Address - City:RED BOILING SPRINGS
Practice Address - State:TN
Practice Address - Zip Code:37150-2149
Practice Address - Country:US
Practice Address - Phone:270-255-1192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPT003345225100000X
TN9487225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000487013OtherANTHEM
KY00028001Medicare PIN