Provider Demographics
NPI:1124246889
Name:E.B. ROSS, JR MD-STEPHEN D GOODWIN, MD
Entity type:Organization
Organization Name:E.B. ROSS, JR MD-STEPHEN D GOODWIN, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:504-391-7650
Mailing Address - Street 1:120 MEADOWCREST ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056-5255
Mailing Address - Country:US
Mailing Address - Phone:504-391-7650
Mailing Address - Fax:504-394-7344
Practice Address - Street 1:120 MEADOWCREST ST
Practice Address - Street 2:SUITE 200
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-5255
Practice Address - Country:US
Practice Address - Phone:504-391-7650
Practice Address - Fax:504-394-7344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1146099Medicaid
LA1337994Medicaid
LA1379689Medicaid
LA1146099Medicaid
LA55436DE70Medicare PIN
LA55436Medicare PIN
LA5DE70Medicare PIN
LA52144Medicare PIN