Provider Demographics
NPI:1881324127
Name:MAMMOSER, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MAMMOSER
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 1:417 HILL RD N
Mailing Address - Street 2:
Mailing Address - City:PICKERINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43147-1310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5959 BIG TREE RD STE 108
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-2291
Practice Address - Country:US
Practice Address - Phone:716-204-3200
Practice Address - Fax:716-204-4337
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA225100000X
VA2305215120225100000X
225100000X
OHPT019942225100000X
NY051204225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist