Basic Information
| Provider Information | |||||||||
| NPI: | 1487253266 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUSAN ROSS OD PROFESSIONAL CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 211 E BROADWAY | ||||||||
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| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184629818 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8900 MENTOR AVE | ||||||||
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| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440606345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402557727 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2020 | ||||||||
| LastUpdateDate: | 10/22/2020 | ||||||||
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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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| NPICertificationDate: | 10/20/2020 | ||||||||
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.