=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932590601
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MODERN PHYSICIAN SERVICES PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2015
-----------------------------------------------------
Last Update Date | 06/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 68 GRAHAM AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11206-4017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 644-593-8773
-----------------------------------------------------
Fax | 417-429-2893
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 85 BROAD ST FL 18
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10004-2783
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-604-8120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ANDREW SHULMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 646-741-1511
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0002X
-----------------------------------------------------
Taxonomy Name | Emergency Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------