Provider Demographics
NPI:1851516736
Name:MODERN IMAGE OF NY
Entity type:Organization
Organization Name:MODERN IMAGE OF NY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:
Authorized Official - First Name:RAISA
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-996-9088
Mailing Address - Street 1:2965 OCEAN PKWY
Mailing Address - Street 2:507
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-8014
Mailing Address - Country:US
Mailing Address - Phone:718-996-9088
Mailing Address - Fax:718-535-7876
Practice Address - Street 1:2965 OCEAN PKWY
Practice Address - Street 2:507
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-8014
Practice Address - Country:US
Practice Address - Phone:718-996-9088
Practice Address - Fax:718-535-7876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01832017Medicaid
NY01832017Medicaid