1033650056 NPI number — PAIN MODULATION ASSOCIATES PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033650056 NPI number — PAIN MODULATION ASSOCIATES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN MODULATION ASSOCIATES PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033650056
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44 CASTLE VIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLOUCESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01930-1519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-710-8440
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
480 MAPLE ST
Provider Second Line Business Practice Location Address:
PAIN MANAGEMENT CENTER
Provider Business Practice Location Address City Name:
DANVERS
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01923-4065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-304-8601
Provider Business Practice Location Address Fax Number:
978-304-8621
Provider Enumeration Date:
03/09/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BRANTON
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
781-710-8440

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  151081 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3157113 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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