Provider Demographics
NPI:1699367672
Name:MODERN AUDIOLOGY
Entity Type:Organization
Organization Name:MODERN AUDIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVENIERE
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:718-813-8361
Mailing Address - Street 1:666 W END AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-7461
Mailing Address - Country:US
Mailing Address - Phone:718-813-8361
Mailing Address - Fax:
Practice Address - Street 1:220 E 161ST ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-3543
Practice Address - Country:US
Practice Address - Phone:718-813-8361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1548448798OtherNPI