Provider Demographics
NPI:1457450413
Name:LIYANAGE, MODINI CHINTHA (MD)
Entity Type:Individual
Prefix:MRS
First Name:MODINI
Middle Name:CHINTHA
Last Name:LIYANAGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:734-729-5780
Mailing Address - Fax:734-729-7730
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:734-729-7730
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074724207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI023685OtherMIDWEST HEALTH PLAN
MI4301074724OtherLICENCE NUMBER
MI139077OtherPREFERRED CHOICES PPO PIN
IDH98425OtherHAP PIN
MI00000009780AOtherCAPE HEALTH PLAN PIN
MI700H221880OtherBCBSM GROUP PIN
MI139077OtherCARE CHOICES PIN
MI2725155OtherCIGNA PIN
MI7589557OtherAETNA PIN
MI4626563Medicaid
MI139077OtherCARE CHOICES PIN
MI700H221880OtherBCBSM GROUP PIN
MI4301074724OtherLICENCE NUMBER
MI023685OtherMIDWEST HEALTH PLAN