Basic Information
| Provider Information | |||||||||
| NPI: | 1528220902 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | CHRISTIAN | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6276 | ||||||||
| Address2: | DPT 20 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462066276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178023143 | ||||||||
| FaxNumber: | 3178700499 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 N RITTER AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462193027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178023143 | ||||||||
| FaxNumber: | 3178700499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2008 | ||||||||
| LastUpdateDate: | 12/20/2011 | ||||||||
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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 | 207P00000X | 01067465 | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 390200000X | 11014389A | IN | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 201109650 | 05 | IN | MEDICAID |