Basic Information
| Provider Information | |||||||||
| NPI: | 1558392837 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1108 | ||||||||
| Address2: | ATTN: LYNDA THOMPSON | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481061108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346777400 | ||||||||
| FaxNumber: | 7346777407 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 HARRINGTON ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT CLEMENS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480432920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864938098 | ||||||||
| FaxNumber: | 5864938706 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 2085R0202X | 5101005626 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 3524765 | 05 | MI | MEDICAID | 3155015635 | 01 | MI | BCBS INDIVIDUAL# | OTHER |