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General NPI Number Information
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NPI Number | 1114953817
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Entity Type | Individual
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Provider Name | RYAN EDWARD MODLINSKI M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/24/2006
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Last Update Date | 07/12/2016
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Provider Practice Location Address
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Address Line | 4123 DUTCHMANS LN SUITE 401
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City | LOUISVILLE
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State | KY
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Zip | 40207-4707
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Country | US
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Telephone | 502-394-6341
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Fax | 502-394-6340
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Provider Business Mailing Address
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Address Line | PO BOX 776351
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City | CHICAGO
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State | IL
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Zip | 60677-6351
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Country | US
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Telephone | 502-588-9490
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Fax | 502-272-5119
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number | TP313
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License Number State | KY
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