Basic Information
| Provider Information | |||||||||
| NPI: | 1417944349 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4201 EXCELSIOR BLVD | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554164728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529338900 | ||||||||
| FaxNumber: | 9529459536 | ||||||||
| Practice Location | |||||||||
| Address1: | 4201 EXCELSIOR BLVD | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529338900 | ||||||||
| FaxNumber: | 9529459536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2005 | ||||||||
| LastUpdateDate: | 12/04/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 21367 | AZ | N | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | 29881 | MN | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 130684 | 05 | AZ | MEDICAID |