1790778876 NPI number — MARYANNE E MODRAK MD

Table of content: MARYANNE E MODRAK MD (NPI 1790778876)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790778876 NPI number — MARYANNE E MODRAK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MODRAK
Provider First Name:
MARYANNE
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1790778876
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33 LEWIS ROAD
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
BINGHAMTON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13903-5227
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-729-8156
Provider Business Mailing Address Fax Number:
607-729-3982

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
507 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13790-1810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-763-8008
Provider Business Practice Location Address Fax Number:
607-763-8019
Provider Enumeration Date:
08/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  162487-1 , 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: 01025754 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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