Provider Demographics
NPI:1245291384
Name:ROSS, RUSSELL A (MD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:A
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 1:520 MOUNTAIN VIEW RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:SC
Mailing Address - Zip Code:29697-9601
Mailing Address - Country:US
Mailing Address - Phone:864-225-0313
Mailing Address - Fax:
Practice Address - Street 1:520 MOUNTAIN VIEW RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:SC
Practice Address - Zip Code:29697-9601
Practice Address - Country:US
Practice Address - Phone:864-225-0313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19015207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG63008Medicare UPIN