MEDICARE: MODERN SPINE AND PAIN PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	174400000X	Specialist
2	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician
3	208VP0014X	Interventional Pain Medicine Physician
4	208VP0000X	Pain Medicine Physician

General Provider Information

NPI Number	:	1174240352
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN SPINE AND PAIN PC

Provider Business Mailing Address
First Line	:	PO BOX 358
Second Line	:
City	:	DOUGLASSVILLE
State	:	PA
Zip	:	19518-0358
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	196 GROVE AVE STE E
Second Line	:
City	:	WEST DEPTFORD
State	:	NJ
Zip	:	08086-2139
Country	:	US
Telephone Number	:	856-900-0041
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	AMANDA L RICCA
Credential	:
Telephone Number	:	215-651-8180

Provider Enumeration Date	:	10/27/2022
Last Update Date	:	02/24/2023

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Directions to “MODERN SPINE AND PAIN PC ” Practice Location

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