Provider Demographics
NPI:1649232026
Name:COMMONWEALTH INFECTIOUS DISEASE PSC
Entity Type:Organization
Organization Name:COMMONWEALTH INFECTIOUS DISEASE PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:XIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-948-5159
Mailing Address - Street 1:PO BOX 32172
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40232-2172
Mailing Address - Country:US
Mailing Address - Phone:502-896-8299
Mailing Address - Fax:
Practice Address - Street 1:3910 S DUPONT SQ
Practice Address - Street 2:SUITE A
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4615
Practice Address - Country:US
Practice Address - Phone:502-896-8299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33270207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65905838Medicaid
KY65905838Medicaid