Provider Demographics
NPI:1538864673
Name:MODERN SPINE PLLC
Entity type:Organization
Organization Name:MODERN SPINE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NEUROLOGICAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:YAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:971-220-1970
Mailing Address - Street 1:15101 NE 193RD CT
Mailing Address - Street 2:
Mailing Address - City:BRUSH PRAIRIE
Mailing Address - State:WA
Mailing Address - Zip Code:98606-3915
Mailing Address - Country:US
Mailing Address - Phone:971-220-1970
Mailing Address - Fax:
Practice Address - Street 1:15101 NE 193RD CT
Practice Address - Street 2:
Practice Address - City:BRUSH PRAIRIE
Practice Address - State:WA
Practice Address - Zip Code:98606-3915
Practice Address - Country:US
Practice Address - Phone:971-220-1970
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-30
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty