Provider Demographics
NPI:1053591321
Name:DR. MARK S. MASSIE, L.L.C.
Entity type:Organization
Organization Name:DR. MARK S. MASSIE, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:MASSIE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:216-221-2445
Mailing Address - Street 1:PO BOX 40450
Mailing Address - Street 2:
Mailing Address - City:BAY VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44140-0450
Mailing Address - Country:US
Mailing Address - Phone:440-871-4700
Mailing Address - Fax:440-871-4702
Practice Address - Street 1:15644 MADISON AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-5622
Practice Address - Country:US
Practice Address - Phone:216-221-2445
Practice Address - Fax:216-221-5891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3074213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2876351Medicaid
OHDE5695OtherMEDICARE RAILROAD GROUP PIN NUMBER
OH5702110001Medicare NSC
OH9360721Medicare PIN