1053591321 NPI number — DR. MARK S. MASSIE, L.L.C.

Table of content: (NPI 1689784753)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053591321 NPI number — DR. MARK S. MASSIE, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. MARK S. MASSIE, L.L.C.
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:
Provider Other Organization Name Type Code:
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:
1053591321
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 40450
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAY VILLAGE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44140-0450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-871-4700
Provider Business Mailing Address Fax Number:
440-871-4702

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15644 MADISON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44107-5622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-221-2445
Provider Business Practice Location Address Fax Number:
216-221-5891
Provider Enumeration Date:
11/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MASSIE
Authorized Official First Name:
MARK
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PODIATRIST
Authorized Official Telephone Number:
216-221-2445

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  3074 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2876351 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: DE5695 . This is a "MEDICARE RAILROAD GROUP PIN NUMBER" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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