MEDICARE: MR. MARC JOSEPH MOLLO ATC

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	A0000995	MD

General Provider Information

NPI Number	:	1699233460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARC JOSEPH MOLLO ATC

Provider Business Mailing Address
First Line	:	16 PENN DR
Second Line	:
City	:	SEWELL
State	:	NJ
Zip	:	08080-1720
Country	:	US
Telephone Number	:	609-980-5132
Fax Number	:

Provider Business Practice Location Address
First Line	:	2755 AUGUSTINE HERMAN HWY
Second Line	:
City	:	CHESAPEAKE CITY
State	:	MD
Zip	:	21915-1408
Country	:	US
Telephone Number	:	410-885-2075
Fax Number	:

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

Provider Enumeration Date	:	03/11/2019
Last Update Date	:	03/11/2019

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