Basic Information
| Provider Information | |||||||||
| NPI: | 1124071998 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | MARY KAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 JOHNSTON ST | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314055502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123521234 | ||||||||
| FaxNumber: | 9123520492 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 WATERS AVE | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314046220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123503849 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 03/30/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 55437 | GA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | BH5598199 | 01 | GA | DEA | OTHER | 000727504B | 05 | GA | MEDICAID | Q21432 | 05 | SC | MEDICAID | 000727504B | 01 | GA | PEACH STATE HEALTH PLAN | OTHER | 215114 | 01 | GA | BLUE CROSS BLUE SHIELD | OTHER | N362168 | 01 | GA | WELLCARE | OTHER | 10064506 | 01 | GA | AMERIGROUP | OTHER |