Basic Information
| Provider Information | |||||||||
| NPI: | 1184235970 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOLLOSKY | ||||||||
| FirstName: | JAMES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4225 GENESEE ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142251994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162043200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4225 GENESEE ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142251994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162043200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2020 | ||||||||
| LastUpdateDate: | 08/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 028524 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist | 2255A2300X | 000064-1 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
ID Information
| ID | Type | State | Issuer | Description | 069702653 | 01 | BOC | OTHER | 951618 | 01 | NATA | OTHER | 000064-1 | 01 | NY | ATHLETIC TRAINER | OTHER |