Provider Demographics
NPI:1396960308
Name:WAYNE MEDICAL CENTER PLLC
Entity type:Organization
Organization Name:WAYNE MEDICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MODINI
Authorized Official - Middle Name:CHINTA
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: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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074724207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI611793200OtherUSPOSTAL WORKMEN COMP
MI139077OtherCARE CHOICES
MIK583OtherMCARE GROUP NUMBER
MI023685OtherMIDWEST HEALTH PLAN
MI700H221880OtherBCBSM GROUP NUMBER
MI700H221880OtherBCN GROUP NUMBER
MI16625OtherMCARE INDIVIDUAL NUMBER
MI7589557OtherAETNA
MIH98425OtherHAP NUMBER
MIP00213848OtherRAILROAD MEDICARE
MI139077OtherPREFERRED CHOICES
MI4626563Medicaid
MI4626563Medicaid
MI16625OtherMCARE INDIVIDUAL NUMBER
MI611793200OtherUSPOSTAL WORKMEN COMP
MI139077OtherCARE CHOICES