Provider Demographics
NPI:1275148611
Name:ROSS, MICHAEL KENNETH
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KENNETH
Last Name:ROSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 E CROSS ST
Mailing Address - Street 2:
Mailing Address - City:OAK HILL
Mailing Address - State:OH
Mailing Address - Zip Code:45656-1246
Mailing Address - Country:US
Mailing Address - Phone:740-418-4828
Mailing Address - Fax:
Practice Address - Street 1:114 E CROSS ST
Practice Address - Street 2:
Practice Address - City:OAK HILL
Practice Address - State:OH
Practice Address - Zip Code:45656-1246
Practice Address - Country:US
Practice Address - Phone:740-418-4828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-12
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747P1801X
OH376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0306650Medicaid