Provider Demographics
NPI:1740275932
Name:ROSS, CHARLES S (DO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:ROSS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2570 NW EDENBOWER BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-6214
Mailing Address - Country:US
Mailing Address - Phone:541-957-1111
Mailing Address - Fax:541-677-0050
Practice Address - Street 1:2570 NW EDENBOWER BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471
Practice Address - Country:US
Practice Address - Phone:541-957-1111
Practice Address - Fax:541-957-5705
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2010-03-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ORDO10012207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR168395Medicaid
R103163OtherMEDICARE PART B
OR000188024OtherBCBS
OR165878Medicaid
E05158Medicare UPIN
132257Medicare ID - Type Unspecified
OR168395Medicaid