Basic Information
Provider Information | |||||||||
NPI: | 1841290129 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROSS | ||||||||
FirstName: | SCOTT | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 300 SINGLETON RIDGE RD | ||||||||
Address2: | ATTENTION PATIENT ACCOUNTING | ||||||||
City: | CONWAY | ||||||||
State: | SC | ||||||||
PostalCode: | 295269142 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8432346827 | ||||||||
FaxNumber: | 8432346990 | ||||||||
Practice Location | |||||||||
Address1: | 5010 CAROLINA FOREST BLVD | ||||||||
Address2: |   | ||||||||
City: | MYRTLE BEACH | ||||||||
State: | SC | ||||||||
PostalCode: | 295793579 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8432362700 | ||||||||
FaxNumber: | 8432362726 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/28/2005 | ||||||||
LastUpdateDate: | 03/26/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/26/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101053663 | VA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 83593 | SC | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1841290129 | 05 | VA |   | MEDICAID | 5632986 | 05 | VA |   | MEDICAID |