Provider Demographics
NPI:1134661143
Name:WAYNE MEDICAL CENTER PLLC
Entity Type:Organization
Organization Name:WAYNE MEDICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MODINI
Authorized Official - Middle Name:C
Authorized Official - Last Name:LIYANAGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-729-5780
Mailing Address - Street 1:1203 S WAYNE RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48186-4362
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1203 S WAYNE RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186-4362
Practice Address - Country:US
Practice Address - Phone:734-729-5780
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDD1992OtherRR MR
MI4626563Medicaid
MI1396960308OtherNPI TYPE 2
MI4626563Medicaid