Provider Demographics
NPI:1861051591
Name:MODERN MEDICAL GROUP PLLC
Entity type:Organization
Organization Name:MODERN MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IVETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:CINTRON-CUBERO
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:704-497-9544
Mailing Address - Street 1:10619 TROLLEY RUN DR
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-8303
Mailing Address - Country:US
Mailing Address - Phone:704-497-9544
Mailing Address - Fax:
Practice Address - Street 1:936 COX RD STE A
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-3456
Practice Address - Country:US
Practice Address - Phone:704-497-9544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC56545-1730570136Medicaid