Basic Information
| Provider Information | |||||||||
| NPI: | 1538275334 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MODLIN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | FREDERIC | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037561000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036536041 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037561000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036536041 | ||||||||
| FaxNumber: | 6036536050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 07/19/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0208X | 8561 | NH | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases |
ID Information
| ID | Type | State | Issuer | Description | 80001647 | 05 | NH | MEDICAID | 0001647 | 05 | VT | MEDICAID |