Provider Demographics
NPI:1508045386
Name:BRANDON ROSS MD PC
Entity Type:Organization
Organization Name:BRANDON ROSS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-524-2121
Mailing Address - Street 1:2950 E WATTLES RD STE 300
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-7008
Mailing Address - Country:US
Mailing Address - Phone:248-524-2121
Mailing Address - Fax:248-524-2035
Practice Address - Street 1:2950 E WATTLES RD STE 300
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-7008
Practice Address - Country:US
Practice Address - Phone:248-524-2121
Practice Address - Fax:248-524-2035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBR407448174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI103327532Medicaid
MI103327532Medicaid
MI0M38680Medicare PIN