Provider Demographics
NPI:1174603492
Name:ROSS, CHARLES ALAN (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ALAN
Last Name:ROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:C
Other - Middle Name:ALAN
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 14883
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27415-4883
Mailing Address - Country:US
Mailing Address - Phone:336-294-6190
Mailing Address - Fax:336-294-6278
Practice Address - Street 1:1210 NEW GARDEN RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-2721
Practice Address - Country:US
Practice Address - Phone:336-294-6190
Practice Address - Fax:336-294-6278
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32960207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC45805OtherMEDCOST
NC11938OtherPARTNERS MEDICARE
NC73292OtherBCBS OF NC
NC8973292Medicaid
NC080080551Medicare PIN
NC73292OtherBCBS OF NC
D18840Medicare UPIN