Basic Information
| Provider Information | |||||||||
| NPI: | 1467679621 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | P.T., ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4660 RIVERSIDE PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312101395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784742114 | ||||||||
| FaxNumber: | 4784745043 | ||||||||
| Practice Location | |||||||||
| Address1: | 4660 RIVERSIDE PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312101395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784742114 | ||||||||
| FaxNumber: | 4784745043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 06/23/2010 | ||||||||
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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 | 225100000X | 007019 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2255A2300X | AT000866 | GA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.