Provider Demographics
NPI:1114387529
Name:P J NOSS CORPORATION
Entity Type:Organization
Organization Name:P J NOSS CORPORATION
Other - Org Name:PJ NOSS LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:NOSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:218-310-8050
Mailing Address - Street 1:1924 DUNEDIN AVE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55803-2400
Mailing Address - Country:US
Mailing Address - Phone:218-310-8050
Mailing Address - Fax:
Practice Address - Street 1:1924 DUNEDIN AVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55803-2400
Practice Address - Country:US
Practice Address - Phone:218-312-3002
Practice Address - Fax:218-236-8933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1114387529Medicaid
1114387529OtherBLUE CROSS BLUE SHIELD
MN1114387529Medicaid