Basic Information
| Provider Information | |||||||||
| NPI: | 1528178076 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MODI MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 FAIRLAND DRIVE | ||||||||
| Address2: | |||||||||
| City: | NITRO | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042042430 | ||||||||
| FaxNumber: | 3043976740 | ||||||||
| Practice Location | |||||||||
| Address1: | 4605 MACCORKLE AVE SW STE 302 | ||||||||
| Address2: | |||||||||
| City: | SOUTH CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253091311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042042430 | ||||||||
| FaxNumber: | 3043976740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 10/20/2017 | ||||||||
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| AuthorizedOfficialLastName: | MODI | ||||||||
| AuthorizedOfficialFirstName: | JIGNESH | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3042042430 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD PA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 19795 | WV | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 9341491 | 01 | PTAN | OTHER | 0300025000 | 05 | WV | MEDICAID |