Provider Demographics
NPI:1861890493
Name:MODERN FAMILY MEDICINE PC
Entity type:Organization
Organization Name:MODERN FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDRIANOVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-512-9435
Mailing Address - Street 1:258 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-3443
Mailing Address - Country:US
Mailing Address - Phone:631-517-9170
Mailing Address - Fax:631-517-9113
Practice Address - Street 1:258 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-3443
Practice Address - Country:US
Practice Address - Phone:631-517-9170
Practice Address - Fax:631-517-9113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-13
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY272088261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care