Provider Demographics
NPI:1821133141
Name:COMMONWEALTH FAMILY PHYSICIANS PSC
Entity Type:Organization
Organization Name:COMMONWEALTH FAMILY PHYSICIANS PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:CALVIN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:859-278-8421
Mailing Address - Street 1:1000 MONARCH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1899
Mailing Address - Country:US
Mailing Address - Phone:859-278-8421
Mailing Address - Fax:859-278-1751
Practice Address - Street 1:1000 MONARCH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1899
Practice Address - Country:US
Practice Address - Phone:859-278-8421
Practice Address - Fax:859-278-1751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02349207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100244500Medicaid
KY7100244500Medicaid
KY8081Medicare PIN