Provider Demographics
NPI:1770741498
Name:COMMONWEALTH SPECIALISTS OF KENTUCKY LLC
Entity type:Organization
Organization Name:COMMONWEALTH SPECIALISTS OF KENTUCKY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TEDRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-352-2530
Mailing Address - Street 1:279 KINGS DAUGHTERS DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-6514
Mailing Address - Country:US
Mailing Address - Phone:502-352-2530
Mailing Address - Fax:
Practice Address - Street 1:279 KINGS DAUGHTERS DR
Practice Address - Street 2:SUITE 308
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-6514
Practice Address - Country:US
Practice Address - Phone:502-352-2530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
163WG0000X, 208VP0000X
KY34363L00000X
KY19363A00000X, 207RG0100X, 208600000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty