Provider Demographics
NPI:1811752900
Name:MODERN MEDICAL GROUP INC
Entity type:Organization
Organization Name:MODERN MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-396-9517
Mailing Address - Street 1:5139 MATTIS RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2250
Mailing Address - Country:US
Mailing Address - Phone:314-396-9517
Mailing Address - Fax:
Practice Address - Street 1:5139 MATTIS RD STE 102
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2250
Practice Address - Country:US
Practice Address - Phone:314-396-9517
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-16
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatricGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty