Provider Demographics
NPI:1235454646
Name:COMMONWEALTH INTERNAL MEDICINE AND PEDIATRICS
Entity Type:Organization
Organization Name:COMMONWEALTH INTERNAL MEDICINE AND PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:KEENE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-907-4299
Mailing Address - Street 1:PO BOX 713
Mailing Address - Street 2:1532 SLATE CREEK ROAD SUITE 106
Mailing Address - City:GRUNDY
Mailing Address - State:VA
Mailing Address - Zip Code:24614-0713
Mailing Address - Country:US
Mailing Address - Phone:276-935-1592
Mailing Address - Fax:
Practice Address - Street 1:1532 SLATE CREEK RD STE 106
Practice Address - Street 2:BOX 173
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614-6975
Practice Address - Country:US
Practice Address - Phone:276-935-1592
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101246820207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty