Provider Demographics
NPI:1760521959
Name:MODERN MEDICAL PRACTICE PLLC
Entity Type:Organization
Organization Name:MODERN MEDICAL PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:OXANA
Authorized Official - Middle Name:
Authorized Official - Last Name:POPESCU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-627-7591
Mailing Address - Street 1:PO BOX 110
Mailing Address - Street 2:
Mailing Address - City:HASTINGS ON HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:10706-0110
Mailing Address - Country:US
Mailing Address - Phone:914-478-5121
Mailing Address - Fax:866-862-1608
Practice Address - Street 1:30 MAIN ST FL 1
Practice Address - Street 2:
Practice Address - City:HASTINGS ON HUDSON
Practice Address - State:NY
Practice Address - Zip Code:10706-1602
Practice Address - Country:US
Practice Address - Phone:914-478-5121
Practice Address - Fax:866-862-1608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY238747 1261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY439 AK1OtherBLUE CROSS
NYP3563394OtherOXFORD
NY02794461Medicaid
NY11178594OtherCAQH
NY4798435OtherGHI
NY0127711OtherGHI
NY12499367OtherAETNA HMO
NY7693186OtherAETNA PPO
NY796340OtherMVP
NYCDPHPOther10110969AP39
NY0127711OtherGHI
NY439 AK1OtherBLUE CROSS