Modern Diagnostic Laboratory, Inc

Primary specialty

Clinical Medical LaboratoryTaxonomy code 291U00000X

License

PFI: 3848 Issued in NY

Legal business name

MODERN DIAGNOSTIC LABORATORY, INC

Practice address

1412 Bay Ridge Ave
Brooklyn, NY 11219-6231

Phone

(718) 837-5222

Fax

(718) 259-0088

NPI assigned

Jun 27, 2005

Last updated

Apr 20, 2008By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Aron Tessler

Title

Treasurer

Phone

(718) 837-5222

Specialties & licenses 1

Addresses

Other identifiers 3

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1119830400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1208649600000",
    "number": "1720084551",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1412 BAY RIDGE AVE",
            "city": "BROOKLYN",
            "state": "NY",
            "postal_code": "112196231",
            "telephone_number": "718-837-5222",
            "fax_number": "718-259-0088"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1412 BAY RIDGE AVE",
            "city": "BROOKLYN",
            "state": "NY",
            "postal_code": "112196231",
            "telephone_number": "718-837-5222",
            "fax_number": "718-259-0088"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MODERN DIAGNOSTIC LABORATORY, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-06-27",
        "last_updated": "2008-04-20",
        "status": "A",
        "authorized_official_last_name": "TESSLER",
        "authorized_official_first_name": "ARON",
        "authorized_official_title_or_position": "TREASURER",
        "authorized_official_telephone_number": "718-837-5222",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "NY",
            "license": "PFI: 3848",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "01064002",
            "state": "NY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0823708",
            "state": "NJ"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "EMPIRE BC/BS",
            "identifier": "L062010",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 20, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.