Provider Demographics
NPI:1447434642
Name:THOMAS ROSS
Entity type:Organization
Organization Name:THOMAS ROSS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:AUDIOLOGIST
Authorized Official - Phone:662-235-5685
Mailing Address - Street 1:PO BOX 753
Mailing Address - Street 2:
Mailing Address - City:TCHULA
Mailing Address - State:MS
Mailing Address - Zip Code:39169-0753
Mailing Address - Country:US
Mailing Address - Phone:662-235-5685
Mailing Address - Fax:
Practice Address - Street 1:605 POPLAR ST
Practice Address - Street 2:
Practice Address - City:TCHULA
Practice Address - State:MS
Practice Address - Zip Code:39169
Practice Address - Country:US
Practice Address - Phone:662-235-5685
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA1198231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014870Medicaid