Provider Demographics
NPI:1417267683
Name:COMMONWEALTH ALLERGY AND ASTHMA LLC
Entity Type:Organization
Organization Name:COMMONWEALTH ALLERGY AND ASTHMA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:CREASY
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-379-2707
Mailing Address - Street 1:201 CONCOURSE BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5640
Mailing Address - Country:US
Mailing Address - Phone:804-968-4824
Mailing Address - Fax:804-968-4826
Practice Address - Street 1:201 CONCOURSE BLVD
Practice Address - Street 2:STE 100
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-5640
Practice Address - Country:US
Practice Address - Phone:804-968-4824
Practice Address - Fax:804-968-4826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-20
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101239959207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1932130531Medicaid
VA00Y236A02OtherMEDICARE
VA00Y236A02OtherMEDICARE