Provider Demographics
NPI:1134251895
Name:LYLE T. MODLIN, DPM PA
Entity type:Organization
Organization Name:LYLE T. MODLIN, DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RENEAU
Authorized Official - Middle Name:
Authorized Official - Last Name:ZEPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-263-3100
Mailing Address - Street 1:43 OLD SOLOMONS ISLAND RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3850
Mailing Address - Country:US
Mailing Address - Phone:410-263-3100
Mailing Address - Fax:410-263-7380
Practice Address - Street 1:43 OLD SOLOMONS ISLAND RD
Practice Address - Street 2:SUITE 102
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3850
Practice Address - Country:US
Practice Address - Phone:410-263-3100
Practice Address - Fax:410-263-7380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00631213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD463068800Medicaid
MD408190100Medicaid
MD0908620001Medicare NSC
MD388MMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
MD539FMedicare ID - Type UnspecifiedMEDICARE INDIVIDUAL NUMBE
MD463068800Medicaid