MEDICARE: SAM MOLOS MSPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	21299	NY

General Provider Information

NPI Number	:	1427121276
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAM MOLOS MSPT

Provider Business Mailing Address
First Line	:	408 LATHAM RD
Second Line	:
City	:	MINEOLA
State	:	NY
Zip	:	11501-1007
Country	:	US
Telephone Number	:	516-746-0855
Fax Number	:

Provider Business Practice Location Address
First Line	:	3201 QUENTIN RD
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-4236
Country	:	US
Telephone Number	:	718-382-9505
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	07/08/2007

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