Basic Information
| Provider Information | |||||||||
| NPI: | 1588679062 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MODEROW | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CORIO | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1100 BLYTHE BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282035814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043554370 | ||||||||
| FaxNumber: | 7043554231 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 E WT HARRIS BLVD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282623485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045485780 | ||||||||
| FaxNumber: | 7045485876 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 08/22/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 10110 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7211893 | 05 | NC | MEDICAID |