Provider Demographics
NPI:1215936547
Name:COMMONWEALTH FAMILY PRACTICE LTD
Entity type:Organization
Organization Name:COMMONWEALTH FAMILY PRACTICE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:LAND
Authorized Official - Last Name:SIEGRIST
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:804-748-6229
Mailing Address - Street 1:10201 KRAUSE RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-6575
Mailing Address - Country:US
Mailing Address - Phone:804-748-6229
Mailing Address - Fax:804-748-5909
Practice Address - Street 1:10201 KRAUSE RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-6575
Practice Address - Country:US
Practice Address - Phone:804-748-6229
Practice Address - Fax:804-748-5909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102037160208D00000X
VA0102037170208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
287512OtherBLUE CROSS
287512OtherBLUE CROSS-BLUE SHIELD
318871OtherBLUE CROSS/BLUE SHIELD
H9571OtherRAILROAD MEDICARE
318871OtherBLUE CROSS
318871OtherBLUE CROSS/BLUE SHIELD
318871OtherBLUE CROSS
=========OtherCOMMERICAL INSURANCE
G44266Medicare UPIN
VAC07033Medicare PIN