Provider Demographics
NPI:1003849720
Name:COMMONWEALTH EAR, NOSE & THROAT ASSOCIATES, LLC
Entity Type:Organization
Organization Name:COMMONWEALTH EAR, NOSE & THROAT ASSOCIATES, LLC
Other - Org Name:STEPHEN M BANE MD PLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:J
Authorized Official - Last Name:EKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-878-0777
Mailing Address - Street 1:2280 OPITZ BLVD
Mailing Address - Street 2:SUITE 340
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191
Mailing Address - Country:US
Mailing Address - Phone:703-878-0777
Mailing Address - Fax:703-583-1777
Practice Address - Street 1:2280 OPITZ BLVD
Practice Address - Street 2:SUITE 340
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191
Practice Address - Country:US
Practice Address - Phone:703-878-0777
Practice Address - Fax:703-583-1777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VADC5029OtherRAILROAD MEDICARE
VA6500226Medicaid
VA0040000446Medicare NSC
F93811Medicare UPIN
VA6500226Medicaid