1902868730 NPI number — LUCY ELIZABETH MODAHL MD, PHD

Table of content: (NPI 1184951857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902868730 NPI number — LUCY ELIZABETH MODAHL MD, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MODAHL
Provider First Name:
LUCY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD, PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1902868730
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 FRONT AVENUE
Provider Second Line Business Mailing Address:
SUITE #502
Provider Business Mailing Address City Name:
COEUR D ALENE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-415-0524
Provider Business Mailing Address Fax Number:
208-763-3644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 FRONT AVENUE
Provider Second Line Business Practice Location Address:
SUITE #502
Provider Business Practice Location Address City Name:
COEUR D ALENE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-415-0524
Provider Business Practice Location Address Fax Number:
208-763-3644
Provider Enumeration Date:
04/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  M9541 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 101968783 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1019687830001 . This is a "MEDICAL ASSISTANCE PA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50017558 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000548186 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1019687930001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00403958 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 3425955000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1902868730 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3810010476 . This is a "MEDICAID WV" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2950085 . This is a "MEDICAL ASSISTANCE NY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 7100025960 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 91725 . This is a "SIHO" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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