Provider Demographics
NPI:1336157858
Name:COMMONWEALTH PRIMARY CARE
Entity Type:Organization
Organization Name:COMMONWEALTH PRIMARY CARE
Other - Org Name:CPC HOSPITALIST DIVISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HOSPITALIST ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-521-5315
Mailing Address - Street 1:4050 INNSLAKE DR
Mailing Address - Street 2:STE 308
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-3327
Mailing Address - Country:US
Mailing Address - Phone:804-521-5315
Mailing Address - Fax:804-521-5312
Practice Address - Street 1:4050 INNSLAKE DR
Practice Address - Street 2:STE 308
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060
Practice Address - Country:US
Practice Address - Phone:804-521-5310
Practice Address - Fax:804-521-5312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA139444OtherANTHEM BCBS
VACC6597OtherMEDICARE RR
VA139440OtherANTHEM BCBS
VACC6597OtherMEDICARE RR