Basic Information
| Provider Information | |||||||||
| NPI: | 1124246889 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | E.B. ROSS, JR MD-STEPHEN D GOODWIN, MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 MEADOWCREST ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GRETNA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700565255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5043917650 | ||||||||
| FaxNumber: | 5043947344 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 MEADOWCREST ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GRETNA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700565255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5043917650 | ||||||||
| FaxNumber: | 5043947344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 03/17/2009 | ||||||||
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| AuthorizedOfficialLastName: | ROSS | ||||||||
| AuthorizedOfficialFirstName: | EDWIN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5043917650 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 1146099 | 05 | LA | MEDICAID | 1337994 | 05 | LA | MEDICAID | 1379689 | 05 | LA | MEDICAID |