Provider Demographics
NPI:1790920825
Name:COMMONWEALTH BIOMEDICAL RESEARCH, LLC
Entity Type:Organization
Organization Name:COMMONWEALTH BIOMEDICAL RESEARCH, LLC
Other - Org Name:CROFTON FAMILY MEDICAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRET
Authorized Official - Middle Name:A
Authorized Official - Last Name:WITTMER
Authorized Official - Suffix:
Authorized Official - Credentials:DVM / MD
Authorized Official - Phone:270-825-8345
Mailing Address - Street 1:240 E AYR PKY
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-8999
Mailing Address - Country:US
Mailing Address - Phone:270-825-8345
Mailing Address - Fax:270-825-2975
Practice Address - Street 1:136 E PRINCETON ST
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:KY
Practice Address - Zip Code:42217-8018
Practice Address - Country:US
Practice Address - Phone:270-424-8885
Practice Address - Fax:270-424-5193
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONWEALTH BIOMEDICAL RESEARCH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-03
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7570Medicare PIN