Provider Demographics
NPI:1215954771
Name:SHEPHERD, ROSS WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:ROSS
Middle Name:WILLIAM
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1 CHILDRENS PL
Mailing Address - Street 2:C B 8116
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1002
Mailing Address - Country:US
Mailing Address - Phone:314-454-6173
Mailing Address - Fax:314-454-2412
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-454-6173
Practice Address - Fax:314-454-2412
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2010-01-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO20001441732080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205020605Medicaid
IL$$$$$$$$$Medicaid
235010381Medicare PIN
H23794Medicare UPIN
MO205020605Medicaid