Provider Demographics
NPI:1588353593
Name:MODINI LIYANAGE PLLC
Entity type:Organization
Organization Name:MODINI LIYANAGE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
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:248-719-8117
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:734-895-9200
Mailing Address - Fax:734-895-9230
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:248-719-8117
Practice Address - Fax:248-449-8085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-04
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty