Healthcare Provider Details

I. General information

NPI: 1942256821
Provider Name (Legal Business Name): MODERN MEDICINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4114 1ST AVE
NITRO WV
25143
US

IV. Provider business mailing address

4114 1ST AVE
NITRO WV
25143-1304
US

V. Phone/Fax

Practice location:
  • Phone: 304-755-0119
  • Fax: 304-755-0111
Mailing address:
  • Phone: 304-755-0119
  • Fax: 304-755-0111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number11111
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1111
License Number StateWV

VIII. Authorized Official

Name: ELIAS HAIKAL
Title or Position: PRESIDENT
Credential: MD
Phone: 304-755-0119