Provider Demographics
NPI:1194993956
Name:BRADLEY S. ROSS, D.P.M., P.C.
Entity type:Organization
Organization Name:BRADLEY S. ROSS, D.P.M., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:847-673-1818
Mailing Address - Street 1:7126 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-2234
Mailing Address - Country:US
Mailing Address - Phone:847-673-1818
Mailing Address - Fax:847-583-9196
Practice Address - Street 1:7126 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712-2234
Practice Address - Country:US
Practice Address - Phone:847-673-1818
Practice Address - Fax:847-583-9196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004242213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT38550Medicare UPIN
IL796120Medicare PIN