Provider Demographics
NPI:1649833013
Name:ROSS, ANDREW EDWARD
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:EDWARD
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 1:2342 JOHN R RD APT 105
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-2569
Mailing Address - Country:US
Mailing Address - Phone:619-261-4371
Mailing Address - Fax:
Practice Address - Street 1:4160 JOHN R ST STE 1007
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2017
Practice Address - Country:US
Practice Address - Phone:313-966-9471
Practice Address - Fax:313-966-9471
Is Sole Proprietor?:No
Enumeration Date:2019-04-20
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55101027692207YS0123X
390200000X
MI5101027692207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program