Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 119585 | MO |
N | 2080P0204X | Pediatric Emergency Doctor | 119585 | MO |
NPI | 1306863857 |
---|---|
Provider Name | Dr. Kelly L Ross |
First Address | Saint Louis, MO 63110-1002 |
Second Address | Saint Louis, MO 63110-1002 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/07/2006 |
Last Update Date | 15/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
204680417 | (05) | MO |