MEDICARE: MODERN PEDIATRICS OF GREAT NEW YORK, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1558412668
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN PEDIATRICS OF GREAT NEW YORK, PC

Provider Business Mailing Address
First Line	:	194 OCEAN PKWY
Second Line	:	FIRST FLOOR
City	:	BROOKLYN
State	:	NY
Zip	:	11218-2408
Country	:	US
Telephone Number	:	718-853-8249
Fax Number	:

Provider Business Practice Location Address
First Line	:	194 OCEAN PKWY
Second Line	:	FIRST FLOOR
City	:	BROOKLYN
State	:	NY
Zip	:	11218-2408
Country	:	US
Telephone Number	:	718-853-8249
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	HARRY VICTOR BOND
Credential	:
Telephone Number	:	718-853-8249

Provider Enumeration Date	:	01/15/2007
Last Update Date	:	10/30/2007

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