Basic Information
| Provider Information | |||||||||
| NPI: | 1639699051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | ROSS | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 955 RIBAUT RD | ||||||||
| Address2: | |||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299025454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435227843 | ||||||||
| FaxNumber: | 8435225945 | ||||||||
| Practice Location | |||||||||
| Address1: | 989 RIBAUT RD STE 260 | ||||||||
| Address2: | |||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299025499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435227600 | ||||||||
| FaxNumber: | 8442959674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2017 | ||||||||
| LastUpdateDate: | 06/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | EC171069 | ME | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 84336 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 843369 | 05 | SC | MEDICAID |