Healthcare Provider Details

I. General information

NPI: 1487968970
Provider Name (Legal Business Name): BARBARA M MODIC MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 09/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 N CANFIELD NILES RD SUITE110
AUSTINTOWN OH
44515-2328
US

IV. Provider business mailing address

25 N CANFIELD NILES RD SUITE110
AUSTINTOWN OH
44515-2328
US

V. Phone/Fax

Practice location:
  • Phone: 330-792-2577
  • Fax: 330-792-3199
Mailing address:
  • Phone: 330-792-2577
  • Fax: 330-792-3199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number35055600
License Number StateOH

VIII. Authorized Official

Name: DR. BARBARA MARIE MODIC
Title or Position: OWNER
Credential: M.D.
Phone: 330-792-2577