Individual
LUCY ELIZABETH MODAHL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MD, PHD
Contact information
Practice address
601 FRONT AVENUE, SUITE #502, COEUR D ALENE, ID 83814
(208) 415-0524
(208) 763-3644
Mailing address
601 FRONT AVENUE, SUITE #502, COEUR D ALENE, ID 83814
(208) 415-0524
(208) 763-3644
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
M9541
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000548186
ANTHEM
KY
05
—
101968783
—
PA
01
—
1019687830001
MEDICAL ASSISTANCE PA
PA
05
—
1019687930001
—
PA
05
—
1902868730
—
VA
01
—
2950085
MEDICAL ASSISTANCE NY
PA
01
—
3425955000
PASSPORT ADVANTAGE
KY
01
—
3810010476
MEDICAID WV
VA
01
—
50017558
PASSPORT
KY
05
—
7100025960
—
KY
01
—
91725
SIHO
KY
01
—
P00403958
MEDICARE RAILROAD
VA
Enumeration date
04/05/2006
Last updated
05/26/2009
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