Provider Demographics
NPI:1124053582
Name:ROSS, MICHAEL A (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:ROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3006
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303
Mailing Address - Country:US
Mailing Address - Phone:920-499-1428
Mailing Address - Fax:920-499-5808
Practice Address - Street 1:1789 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303
Practice Address - Country:US
Practice Address - Phone:920-499-1428
Practice Address - Fax:920-499-5808
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32874-0202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1018926002OtherUNITED HEALTHCARE MEDICAI
300030636OtherRR MEDICARE
WI31799500Medicaid
567565OtherDEAN HEALTH
14448OtherDEAN HEALTH
MI4723997Medicaid
MI4767230Medicaid
300030636OtherRR MEDICARE
P0026437Medicare Oscar/Certification
072730008Medicare ID - Type Unspecified
070050003Medicare ID - Type Unspecified
MI4723997Medicaid