Basic Information
Provider Information | |||||||||
NPI: | 1831106152 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MODLIN | ||||||||
FirstName: | PAITRA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 275 BEATTY DR | ||||||||
Address2: |   | ||||||||
City: | BELMONT | ||||||||
State: | NC | ||||||||
PostalCode: | 280122715 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7045123391 | ||||||||
FaxNumber: | 7045123487 | ||||||||
Practice Location | |||||||||
Address1: | 275 BEATTY DR | ||||||||
Address2: |   | ||||||||
City: | BELMONT | ||||||||
State: | NC | ||||||||
PostalCode: | 280122715 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7045123391 | ||||||||
FaxNumber: | 7045123487 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/01/2006 | ||||||||
LastUpdateDate: | 06/17/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1910 | NC | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 112056 | 01 | NC | WELLNESS | OTHER | 59948 | 01 | NC | BCBS | OTHER | 78429 | 01 | NC | MEDCOST | OTHER | 7259948 | 05 | NC |   | MEDICAID | 295464 | 01 | NC | MAMSI | OTHER |