Provider Demographics
NPI:1881699700
Name:ROSS, CAROLYN ANN (DO)
Entity type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:ANN
Last Name:ROSS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:ANN
Other - Last Name:DURHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 DEVONSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2318
Mailing Address - Country:US
Mailing Address - Phone:931-267-7811
Mailing Address - Fax:
Practice Address - Street 1:120 WALNUT COMMONS LN STE B
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501
Practice Address - Country:US
Practice Address - Phone:931-528-2557
Practice Address - Fax:931-526-2559
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1416207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3306792Medicaid
TN3306792Medicaid
TNBR6478778OtherDEA CERTIFICATE