Provider Demographics
NPI:1477564730
Name:MOLLSEN, THOMAS
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:MOLLSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 E GOLF RD STE 100
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-1544
Mailing Address - Country:US
Mailing Address - Phone:847-376-8289
Mailing Address - Fax:224-938-9654
Practice Address - Street 1:1355 E GOLF RD STE 100
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-1544
Practice Address - Country:US
Practice Address - Phone:847-376-8289
Practice Address - Fax:224-938-9654
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013496225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216860Medicare PIN
IL096000486OtherATC LICENSE
IL070013496OtherPT LICENSE
IL214708019Medicare PIN
IL202845067Medicare PIN
IL211585027Medicare PIN