Provider Demographics
NPI:1821695081
Name:MODERN PAIN & SPINE PC
Entity Type:Organization
Organization Name:MODERN PAIN & SPINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ATHANASIOS
Authorized Official - Middle Name:KOSTANDINOS
Authorized Official - Last Name:MANOLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-800-7246
Mailing Address - Street 1:1540 JUAN TABO BLVD NE STE A
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-4460
Mailing Address - Country:US
Mailing Address - Phone:505-800-7246
Mailing Address - Fax:
Practice Address - Street 1:1540 JUAN TABO BLVD NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-4460
Practice Address - Country:US
Practice Address - Phone:505-319-0231
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-01
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty