MEDICARE: DR. SANJIV S MODI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RH0003X	Hematology & Oncology Physician	036093810	IL
2	207RH0003X	Hematology & Oncology Physician	01093925A	IN
3	207RH0003X	Hematology & Oncology Physician	78356	AZ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	830007251	OTHER	IL	MEDICARE RR
3	L77781	OTHER	IL	MEDICARE INDIV ID# FOR GROUP 336140
4	L98056	OTHER	IL	MEDICARE INDIV ID# FOR GROUP 205474

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396730909
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SANJIV S MODI MD

Provider Business Mailing Address
First Line	:	PO BOX 781076
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48278-1076
Country	:	US
Telephone Number	:	317-528-4800
Fax Number	:	317-865-1479

Provider Business Practice Location Address
First Line	:	8955 W 400 N
Second Line	:
City	:	MICHIGAN CITY
State	:	IN
Zip	:	46360-9330
Country	:	US
Telephone Number	:	219-861-5800
Fax Number	:	219-861-5543

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	10/06/2025

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Directions to “ DR. SANJIV S MODI MD” Practice Location

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