Basic Information
| Provider Information | |||||||||
| NPI: | 1275979296 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 272 BENEDICT AVE | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448572374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196688101 | ||||||||
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| Practice Location | |||||||||
| Address1: | 24 HYDE ST | ||||||||
| Address2: | |||||||||
| City: | WAKEMAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448899301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408392226 | ||||||||
| FaxNumber: | 4408391339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2013 | ||||||||
| LastUpdateDate: | 01/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301108033 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 35.135213 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0330079 | 05 | OH | MEDICAID |