Provider Demographics
NPI:1184101065
Name:COMMONWEALTH FOOT & ANKLE SPECIALISTS LLC
Entity type:Organization
Organization Name:COMMONWEALTH FOOT & ANKLE SPECIALISTS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FOOT & ANKLE SPECIALIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:PHILLINGANE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:804-365-5898
Mailing Address - Street 1:4704 BARREL POINT RD
Mailing Address - Street 2:
Mailing Address - City:PRINCE GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23875-2976
Mailing Address - Country:US
Mailing Address - Phone:305-206-7638
Mailing Address - Fax:
Practice Address - Street 1:2552 ALDRIDGE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23834-5306
Practice Address - Country:US
Practice Address - Phone:804-365-5898
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103301225213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0103301225OtherVIRGINIA BOARD OF MEDICINE