Basic Information
| Provider Information | |||||||||
| NPI: | 1023000395 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOLLOY | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | ALEXIS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2241 LLOYD CTR | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972321315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532727777 | ||||||||
| FaxNumber: | 2534264142 | ||||||||
| Practice Location | |||||||||
| Address1: | 3303 SW BOND AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972394501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532727777 | ||||||||
| FaxNumber: | 2534264142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 09/03/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | MD16887 | OR | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | MD00030543 | WA | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 8155694 | 05 | WA | MEDICAID | 8155699 | 05 | WA | MEDICAID | 014667 | 05 | OR | MEDICAID |