Provider Demographics
NPI:1841290129
Name:ROSS, SCOTT A (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:ROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:300 SINGLETON RIDGE RD
Mailing Address - Street 2:ATTN PNS CREDENTIALING
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-9142
Mailing Address - Country:US
Mailing Address - Phone:843-234-6946
Mailing Address - Fax:
Practice Address - Street 1:1100 62ND AVE N
Practice Address - Street 2:STE A
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-2957
Practice Address - Country:US
Practice Address - Phone:843-839-0957
Practice Address - Fax:843-839-0758
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101053663207Q00000X
SC83593207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5632986Medicaid
SC835939Medicaid
VA080006746Medicare ID - Type Unspecified
VA5632986Medicaid
VAVAA113259Medicare PIN