Healthcare Provider Details

I. General information

NPI: 1417057951
Provider Name (Legal Business Name): MODERN MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2006
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 BROADWAY STE 910
NEW YORK NY
10007-3008
US

IV. Provider business mailing address

225 BROADWAY STE 910
NEW YORK NY
10007-3008
US

V. Phone/Fax

Practice location:
  • Phone: 212-571-5000
  • Fax: 212-571-5001
Mailing address:
  • Phone: 212-571-5000
  • Fax: 212-571-5001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number215006
License Number StateNY

VIII. Authorized Official

Name: DR. ILYA KLEYN
Title or Position: MD
Credential:
Phone: 212-571-5000