Provider Demographics
NPI:1841287588
Name:ROSS, MARY ELIZABETH (MD, PHD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:ROSS
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 NE GLEN OAK AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61637-0001
Mailing Address - Country:US
Mailing Address - Phone:309-624-4945
Mailing Address - Fax:309-624-9848
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637
Practice Address - Country:US
Practice Address - Phone:309-624-4945
Practice Address - Fax:309-624-9848
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.1220722080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2534850Medicaid
IL036122072Medicaid
OHR04150771Medicare ID - Type Unspecified
I24736Medicare UPIN