Basic Information
| Provider Information | |||||||||
| NPI: | 1508869090 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 367 W EVANS ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295013429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436694156 | ||||||||
| FaxNumber: | 8436642121 | ||||||||
| Practice Location | |||||||||
| Address1: | 367 W EVANS ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295013429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436694156 | ||||||||
| FaxNumber: | 8436642121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 09/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 11764 | SC | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 9624212 | 01 | SC | GHI | OTHER | 4254796 | 01 | SC | AETNA | OTHER | 621812 | 01 | SC | SELECT HEALTH | OTHER | S327574 | 01 | SC | CIGNA | OTHER | AT6689 | 05 | SC | MEDICAID | 180012103 | 01 | SC | RAILROAD MEDICARE | OTHER | 276873 | 01 | SC | PRIVATE HEALTHCARE SYSTEM | OTHER | 890602C | 05 | NC | MEDICAID |