Provider Demographics
NPI:1831242353
Name:COMMONWEALTH PRIMARY CARE
Entity type:Organization
Organization Name:COMMONWEALTH PRIMARY CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-288-0399
Mailing Address - Street 1:8002 DISCOVERY DR STE 410
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23229
Mailing Address - Country:US
Mailing Address - Phone:804-288-0399
Mailing Address - Fax:804-288-0088
Practice Address - Street 1:4050 INNSLAKE DR STE 308
Practice Address - Street 2:
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?:Yes
Parent Organization LBN:COMMONWEALTH PRIMARY CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-19
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA139440OtherANTHEM
VACC6597OtherMEDICARE RR
VAC09088Medicare PIN