Provider Demographics
NPI:1124071998
Name:ROSS, MARY KAY
Entity type:Individual
Prefix:
First Name:MARY KAY
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 JOHNSTON ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-5502
Mailing Address - Country:US
Mailing Address - Phone:912-352-1234
Mailing Address - Fax:912-352-0492
Practice Address - Street 1:4700 WATERS AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6220
Practice Address - Country:US
Practice Address - Phone:912-350-3849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA55437207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000727504BMedicaid
SCQ21432Medicaid
GA000727504BOtherPEACH STATE HEALTH PLAN
GA215114OtherBLUE CROSS BLUE SHIELD
GAN362168OtherWELLCARE
GA10064506OtherAMERIGROUP
GA10064506OtherAMERIGROUP
GAP00167028Medicare PIN
GAG82975Medicare UPIN
SCQ21432Medicaid