Provider Demographics
NPI:1356406656
Name:COMMONWEALTH SPORTS MEDICINE PC
Entity type:Organization
Organization Name:COMMONWEALTH SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:S
Authorized Official - Last Name:STADLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-270-7750
Mailing Address - Street 1:4300 POUNCEY TRACT RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-6007
Mailing Address - Country:US
Mailing Address - Phone:804-270-7750
Mailing Address - Fax:804-497-8625
Practice Address - Street 1:4300 POUNCEY TRACT RD
Practice Address - Street 2:SUITE F
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-6007
Practice Address - Country:US
Practice Address - Phone:804-270-7750
Practice Address - Fax:804-497-8625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101238212174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG79672Medicare UPIN