Basic Information
| Provider Information | |||||||||
| NPI: | 1114948379 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MODIN | ||||||||
| FirstName: | BRANCE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 512 SKYLINE BLVD | ||||||||
| Address2: | |||||||||
| City: | CLOQUET | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557203787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188791271 | ||||||||
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| Practice Location | |||||||||
| Address1: | 512 SKYLINE BLVD | ||||||||
| Address2: | |||||||||
| City: | CLOQUET | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557203787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188791271 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 12/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 30495 | MN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 237082400 | 05 | MN | MEDICAID |