Provider Demographics
NPI:1720084551
Name:MODERN DIAGNOSTIC LABORATORY, INC
Entity Type:Organization
Organization Name:MODERN DIAGNOSTIC LABORATORY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:ARON
Authorized Official - Middle Name:
Authorized Official - Last Name:TESSLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-837-5222
Mailing Address - Street 1:1412 BAY RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-6231
Mailing Address - Country:US
Mailing Address - Phone:718-837-5222
Mailing Address - Fax:718-259-0088
Practice Address - Street 1:1412 BAY RIDGE AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-6231
Practice Address - Country:US
Practice Address - Phone:718-837-5222
Practice Address - Fax:718-259-0088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPFI: 3848291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01064002Medicaid
NJ0823708Medicaid
NYL062010OtherEMPIRE BC/BS
NYL062010OtherEMPIRE BC/BS
NYL062010Medicare ID - Type Unspecified