MEDICARE: JOHN CARMEN MASCOLA A.T.,C.

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	2255A2300X	Athletic Trainer	25MT00061000	NJ

General Provider Information

NPI Number	:	1366585622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN CARMEN MASCOLA A.T.,C.

Provider Business Mailing Address
First Line	:	3410 RICHMOND CT
Second Line	:
City	:	HILLSBOROUGH
State	:	NJ
Zip	:	08844-5503
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	65 W GREENBROOK RD
Second Line	:
City	:	NORTH CALDWELL
State	:	NJ
Zip	:	07006-4758
Country	:	US
Telephone Number	:	973-228-1200
Fax Number	:

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

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	07/08/2007

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