Basic Information
| Provider Information | |||||||||
| NPI: | 1891840641 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | EVAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 675 N SAINT CLAIR ST STE 20-150 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606115979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126958146 | ||||||||
| FaxNumber: | 3126957030 | ||||||||
| Practice Location | |||||||||
| Address1: | 675 N SAINT CLAIR ST STE 20-150 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606115979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126958146 | ||||||||
| FaxNumber: | 3126957030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 07/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | D71523 | MD | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 036151981 | IL | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 368875601 | 05 | TX | MEDICAID | 55783800 | 05 | MD | MEDICAID | 368875602 | 05 | TX | MEDICAID |