Basic Information
| Provider Information | |||||||||
| NPI: | 1114387529 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | P J NOSS CORPORATION | ||||||||
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| OtherOrganizationName: | PJ NOSS LLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1924 DUNEDIN AVE | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558032400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183108050 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1924 DUNEDIN AVE | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558032400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183123002 | ||||||||
| FaxNumber: | 2182368933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2016 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | NOSS | ||||||||
| AuthorizedOfficialFirstName: | PHYLLIS | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2183108050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1114387529 | 05 | MN | MEDICAID | 1114387529 | 01 | BLUE CROSS BLUE SHIELD | OTHER |