1962580159 NPI number — DR. MARK NOSS LLC

Table of content: (NPI 1962580159)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962580159 NPI number — DR. MARK NOSS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. MARK NOSS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DR. MARK NOSS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962580159
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
328 MUNSON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRAVERSE CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49686-3040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-946-8460
Provider Business Mailing Address Fax Number:
231-946-8507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
328 MUNSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRAVERSE CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49686-3040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-946-8460
Provider Business Practice Location Address Fax Number:
231-946-8507
Provider Enumeration Date:
11/02/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NOSS
Authorized Official First Name:
MARK
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
231-946-8460

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  4901002760 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 900B814120 . This is a "BCBSM- FOR GROUP NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1205814779 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0622010001 . This is a "DMEPOS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5088450 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 900B865060 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".