1760521959 NPI number — MODERN MEDICAL PRACTICE PLLC

Table of content: (NPI 1760521959)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760521959 NPI number — MODERN MEDICAL PRACTICE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MODERN MEDICAL PRACTICE PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760521959
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HASTINGS ON HUDSON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10706-0110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-478-5121
Provider Business Mailing Address Fax Number:
866-862-1608

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 MAIN ST FL 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HASTINGS ON HUDSON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10706-1602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-478-5121
Provider Business Practice Location Address Fax Number:
866-862-1608
Provider Enumeration Date:
02/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
POPESCU
Authorized Official First Name:
OXANA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICER
Authorized Official Telephone Number:
917-627-7591

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  238747 1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 439 AK1 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P3563394 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02794461 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11178594 . This is a "CAQH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 4798435 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0127711 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 12499367 . This is a "AETNA HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7693186 . This is a "AETNA PPO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 796340 . This is a "MVP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: CDPHP . This is a "10110969AP39" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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