Provider Demographics
NPI:1962580159
Name:DR. MARK NOSS LLC
Entity type:Organization
Organization Name:DR. MARK NOSS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:NOSS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:231-946-8460
Mailing Address - Street 1:328 MUNSON AVE
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3040
Mailing Address - Country:US
Mailing Address - Phone:231-946-8460
Mailing Address - Fax:231-946-8507
Practice Address - Street 1:328 MUNSON AVE
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3040
Practice Address - Country:US
Practice Address - Phone:231-946-8460
Practice Address - Fax:231-946-8507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002760152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900B814120OtherBCBSM- FOR GROUP NPI
MI1205814779OtherINDIVIDUAL NPI
MI0622010001OtherDMEPOS
MI5088450Medicaid
MI900B865060OtherBCBS
MI900B814120OtherBCBSM- FOR GROUP NPI
MI0622010001Medicare NSC