Provider Demographics
NPI:1396730909
Name:MODI, SANJIV S (MD)
Entity type:Individual
Prefix:DR
First Name:SANJIV
Middle Name:S
Last Name:MODI
Suffix:
Gender:M
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:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:8955 W 400 N
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-9330
Practice Address - Country:US
Practice Address - Phone:219-861-5800
Practice Address - Fax:219-861-5543
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093810207RH0003X
IN01093925A207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093810Medicaid
IL830007251OtherMEDICARE RR
ILL77781OtherMEDICARE INDIV ID# FOR GROUP 336140
ILL98056OtherMEDICARE INDIV ID# FOR GROUP 205474
ILL98056OtherMEDICARE INDIV ID# FOR GROUP 205474
ILL77781OtherMEDICARE INDIV ID# FOR GROUP 336140
IL205474Medicare PIN