Provider Demographics
NPI:1053594697
Name:TIMOTHY T ROSS MD
Entity type:Organization
Organization Name:TIMOTHY T ROSS MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-254-3663
Mailing Address - Street 1:11500 NE 76TH ST STE A3
Mailing Address - Street 2:PMB 7
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-3901
Mailing Address - Country:US
Mailing Address - Phone:360-254-3663
Mailing Address - Fax:360-254-3719
Practice Address - Street 1:715 S ANDRESEN RD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-7603
Practice Address - Country:US
Practice Address - Phone:360-693-7877
Practice Address - Fax:360-750-6900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00019932314000000X
ORMD12417314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7034572Medicaid
WAG115107400Medicare PIN