MEDICARE: MODERN IMAGE OF NY

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	332B00000X	Durable Medical Equipment & Medical Supplies

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851516736
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN IMAGE OF NY

Provider Business Mailing Address
First Line	:	2965 OCEAN PKWY
Second Line	:	507
City	:	BROOKLYN
State	:	NY
Zip	:	11235-8014
Country	:	US
Telephone Number	:	718-996-9088
Fax Number	:	718-535-7876

Provider Business Practice Location Address
First Line	:	2965 OCEAN PKWY
Second Line	:	507
City	:	BROOKLYN
State	:	NY
Zip	:	11235-8014
Country	:	US
Telephone Number	:	718-996-9088
Fax Number	:	718-535-7876

Authorized Official
Title or Position	:	PRES.
Name	:	RAISA EVANS
Credential	:
Telephone Number	:	718-996-9088

Provider Enumeration Date	:	04/16/2007
Last Update Date	:	09/18/2009

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Directions to “MODERN IMAGE OF NY ” Practice Location

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