Provider Demographics
NPI:1477500361
Name:COMMONWEALTH MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:COMMONWEALTH MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MUTSCHELKNAUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-777-5100
Mailing Address - Street 1:851 S 70TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-3147
Mailing Address - Country:US
Mailing Address - Phone:414-777-5100
Mailing Address - Fax:414-777-5112
Practice Address - Street 1:851 S 70TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-3147
Practice Address - Country:US
Practice Address - Phone:414-777-5100
Practice Address - Fax:414-777-5112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 208000000X, 2085R0202X, 207RC0000X, 207RP1001X, 208100000X, 207UN0901X, 2085U0001X, 225100000X, 2251H1200X, 363A00000X, 225X00000X, 207R00000X
WI1314-029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHandGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21251000Medicaid
WI83880Medicare ID - Type UnspecifiedPT GROUP MEDICARE NUMBER
WI83250Medicare ID - Type UnspecifiedPT GROUP MEDICARE NUMBER
WI02475Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
WI68175Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER