Provider Demographics
NPI:1720200322
Name:MODERN NEUROLOGY, P.C.
Entity Type:Organization
Organization Name:MODERN NEUROLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:HADDAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-365-7104
Mailing Address - Street 1:1010 NORTHERN BOULEVARD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021
Mailing Address - Country:US
Mailing Address - Phone:516-365-7104
Mailing Address - Fax:718-366-0011
Practice Address - Street 1:1010 NORTHERN BOULEVARD
Practice Address - Street 2:SUITE 208
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021
Practice Address - Country:US
Practice Address - Phone:516-365-7104
Practice Address - Fax:718-366-0011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY220993-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty