Basic Information
| Provider Information | |||||||||
| NPI: | 1154980811 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUSAN ROSS OD PROFESSIONAL CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 211 E BROADWAY | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184629818 | ||||||||
| FaxNumber: | 3147414947 | ||||||||
| Practice Location | |||||||||
| Address1: | 33541 AURORA RD | ||||||||
| Address2: | |||||||||
| City: | SOLON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441393705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402482020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2019 | ||||||||
| LastUpdateDate: | 06/06/2019 | ||||||||
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| AuthorizedOfficialLastName: | SHORT | ||||||||
| AuthorizedOfficialFirstName: | CATHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6184629818 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.