Provider Demographics
NPI:1720190390
Name:COMMONWEALTH EAR, NOSE & THROAT SPECIALISTS PC
Entity Type:Organization
Organization Name:COMMONWEALTH EAR, NOSE & THROAT SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:GIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-345-3556
Mailing Address - Street 1:PO BOX 8310
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-0310
Mailing Address - Country:US
Mailing Address - Phone:540-345-3556
Mailing Address - Fax:540-342-2193
Practice Address - Street 1:14051 ST FRANCIS BLVD
Practice Address - Street 2:SUITE 2211
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-3201
Practice Address - Country:US
Practice Address - Phone:540-345-3556
Practice Address - Fax:540-342-2193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA010122975207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA269573OtherANTHEM
VA006501478Medicaid
VA006501478Medicaid
VAC09917Medicare PIN
VA00X147X01Medicare PIN