=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124212246
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THOMAS V MAROLDO, MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2007
-----------------------------------------------------
Last Update Date | 08/31/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 W POPLAR ST
-----------------------------------------------------
City | WALLA WALLA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99362-2846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-525-2220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2300 MSC 10044
-----------------------------------------------------
City | SPOKANE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-525-4878
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | THOMAS V MAROLDO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 509-525-2220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MD00034132
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------