Provider Demographics
NPI:1033650056
Name:PAIN MODULATION ASSOCIATES PLLC
Entity Type:Organization
Organization Name:PAIN MODULATION ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-710-8440
Mailing Address - Street 1:44 CASTLE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-1519
Mailing Address - Country:US
Mailing Address - Phone:781-710-8440
Mailing Address - Fax:
Practice Address - Street 1:480 MAPLE ST
Practice Address - Street 2:PAIN MANAGEMENT CENTER
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-4065
Practice Address - Country:US
Practice Address - Phone:978-304-8601
Practice Address - Fax:978-304-8621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA151081207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3157113Medicaid
G60783Medicare UPIN
MA3157113Medicaid