Provider Demographics
NPI:1669516118
Name:ROSS, GREGORY WAYNE (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:WAYNE
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 1:15 CHARLES PLZ STE 101B
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-3935
Mailing Address - Country:US
Mailing Address - Phone:410-685-8665
Mailing Address - Fax:
Practice Address - Street 1:222 N CHARLES ST STE 101B
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-4032
Practice Address - Country:US
Practice Address - Phone:410-685-8665
Practice Address - Fax:410-685-0272
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-17
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0034677207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDE22137Medicare UPIN
MD471006Medicare ID - Type Unspecified