Basic Information
| Provider Information | |||||||||
| NPI: | 1326044330 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95 COLLIER ROAD | ||||||||
| Address2: | SUITE 5015 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046055699 | ||||||||
| FaxNumber: | 4043554235 | ||||||||
| Practice Location | |||||||||
| Address1: | 95 COLLIER ROAD | ||||||||
| Address2: | SUITE 5015 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046055699 | ||||||||
| FaxNumber: | 4043554235 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2005 | ||||||||
| LastUpdateDate: | 12/10/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 24250 | KY | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | 01066838A | IN | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | 068549 | GA | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 003129136C | 05 | GA | MEDICAID |