Basic Information
Provider Information
NPI: 1003805508
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: NOCK
FirstName: MARY
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 24701 EUCLID AVE
Address2: 3RD FLOOR
City: EUCLID
State: OH
PostalCode: 441171714
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 11100 EUCLID AVENUE
Address2:  
City: CLEVELAND
State: OH
PostalCode: 44106
CountryCode: US
TelephoneNumber: 2168447700
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/18/2005
LastUpdateDate: 07/06/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207L00000X35-076430OHN Allopathic & Osteopathic PhysiciansAnesthesiology 
208000000X35076430OHN Allopathic & Osteopathic PhysiciansPediatrics 
2080N0001X35076430OHY Allopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
207LP3000X35-076430OHN Allopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology

ID Information
IDTypeStateIssuerDescription
36388001OHWELLCAREOTHER
733613801OHAETNAOTHER
00000052611201OHANTHEMOTHER
00000022125701OHUNISONOTHER
101833174000101PAPA MEDICAIDOTHER
219536005OH MEDICAID
74595901OHBUCKEYEOTHER
219536001OHBCMHOTHER


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