Provider Demographics
NPI:1285965079
Name:PJ NOSS LLC
Entity type:Organization
Organization Name:PJ NOSS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:NOSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:218-312-3005
Mailing Address - Street 1:1346 W ARROWHEAD RD # 175
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-2218
Mailing Address - Country:US
Mailing Address - Phone:218-310-8050
Mailing Address - Fax:
Practice Address - Street 1:1200 E 25TH ST
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-3897
Practice Address - Country:US
Practice Address - Phone:218-312-3005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-19
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN442312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN087K5NOOtherBLUE CROSS BLUE SHIELD
MN164104OtherUCARE
MN372124800Medicaid
MN1602543OtherMEDICA
MNDQ0614OtherRAIL ROAD MEDICARE
MN372124800Medicaid