1174524797 NPI number — MODERN MEDICAL, INC.

Table of content: (NPI 1174524797)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174524797 NPI number — MODERN MEDICAL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MODERN MEDICAL, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OPTUM WORKERS COMPENSATION MEDICAL SERVICES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174524797
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 PROGRESSIVE WAY
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
WESTERVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43082-9615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-547-3330
Provider Business Mailing Address Fax Number:
614-212-8008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 PROGRESSIVE WAY
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
WESTERVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43082-9615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-547-3330
Provider Business Practice Location Address Fax Number:
614-212-8008
Provider Enumeration Date:
08/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BENCIVENGA
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
GENERAL COUNSEL
Authorized Official Telephone Number:
813-318-6831

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: HMER 23503 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 347E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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