Provider Demographics
NPI:1982760955
Name:KELLY G ROSS OD PA
Entity Type:Organization
Organization Name:KELLY G ROSS OD PA
Other - Org Name:ROSS EYE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:870-886-2632
Mailing Address - Street 1:1014 W MAIN ST
Mailing Address - Street 2:P.O. BOX 349
Mailing Address - City:WALNUT RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72476-1004
Mailing Address - Country:US
Mailing Address - Phone:870-886-2632
Mailing Address - Fax:870-886-1514
Practice Address - Street 1:1014 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WALNUT RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72476-1004
Practice Address - Country:US
Practice Address - Phone:870-886-2632
Practice Address - Fax:870-886-1514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2485152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR167096722Medicaid
AR5F267OtherBLUE CROSS BLUE SHIELD
AR5F267Medicare ID - Type UnspecifiedGROUP NUMBER
AR6160090001Medicare NSC