Provider Demographics
NPI:1902868730
Name:MODAHL, LUCY ELIZABETH (MD, PHD)
Entity Type:Individual
Prefix:
First Name:LUCY
Middle Name:ELIZABETH
Last Name:MODAHL
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 FRONT AVENUE
Mailing Address - Street 2:SUITE #502
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-415-0524
Mailing Address - Fax:208-763-3644
Practice Address - Street 1:601 FRONT AVENUE
Practice Address - Street 2:SUITE #502
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-415-0524
Practice Address - Fax:208-763-3644
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM95412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101968783Medicaid
PA1019687830001OtherMEDICAL ASSISTANCE PA
KY50017558OtherPASSPORT
KY000000548186OtherANTHEM
PA1019687930001Medicaid
VAP00403958OtherMEDICARE RAILROAD
KY3425955000OtherPASSPORT ADVANTAGE
VA1902868730Medicaid
VA3810010476OtherMEDICAID WV
PA2950085OtherMEDICAL ASSISTANCE NY
KY7100025960Medicaid
KY91725OtherSIHO
PA2950085OtherMEDICAL ASSISTANCE NY
PA1019687830001OtherMEDICAL ASSISTANCE PA
PA101968783Medicaid
PA115250Medicare PIN
KY91725OtherSIHO
PA115250-FLTMedicare PIN
KY7100025960Medicaid
OHMO7375991Medicare PIN