Provider Demographics
NPI:1538339338
Name:MILLARD I. ROSS, M.D., LLC
Entity type:Organization
Organization Name:MILLARD I. ROSS, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MILLARD
Authorized Official - Middle Name:I
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:770-713-2456
Mailing Address - Street 1:2724 HIGHWAY 212 SW
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-3370
Mailing Address - Country:US
Mailing Address - Phone:770-213-2456
Mailing Address - Fax:770-388-0539
Practice Address - Street 1:1412 MILSTEAD AVE NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3877
Practice Address - Country:US
Practice Address - Phone:678-413-7738
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA15315208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000148552BMedicaid