Basic Information
| Provider Information | |||||||||
| NPI: | 1194919100 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSSO | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | ISABEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4166 BUFORD HWY NE | ||||||||
| Address2: | SUITE 1102 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303451081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047858160 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4166 BUFORD HWY NE | ||||||||
| Address2: | SUITE 1102 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303451081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047858160 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2007 | ||||||||
| LastUpdateDate: | 07/07/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD.200995 | LA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 060864 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1238074 | 05 | LA | MEDICAID |