Provider Demographics
NPI:1215558382
Name:COMMONWEALTH CLINICAL GROUP, INC.
Entity Type:Organization
Organization Name:COMMONWEALTH CLINICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:STACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BASHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-393-3900
Mailing Address - Street 1:41 E ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-2846
Mailing Address - Country:US
Mailing Address - Phone:717-393-3900
Mailing Address - Fax:717-393-7900
Practice Address - Street 1:41 E ORANGE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2846
Practice Address - Country:US
Practice Address - Phone:717-393-3900
Practice Address - Fax:717-393-7900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-30
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA336180Medicaid