Provider Demographics
NPI:1982737961
Name:COMMONWEALTH BIOMEDICAL RESEARCH LLC
Entity Type:Organization
Organization Name:COMMONWEALTH BIOMEDICAL RESEARCH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:E
Authorized Official - Last Name:WITTMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-825-8345
Mailing Address - Street 1:240 EAST AYR PKWY
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-8999
Mailing Address - Country:US
Mailing Address - Phone:270-825-8345
Mailing Address - Fax:270-825-2975
Practice Address - Street 1:240 AYER PKWY E
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-8999
Practice Address - Country:US
Practice Address - Phone:270-825-8345
Practice Address - Fax:270-825-2975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171100000X, 1744R1102X, 363AM0700X
KY34849207Q00000X
KY5766P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No1744R1102XOther Service ProvidersSpecialistResearch StudyGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY18D0994667OtherCLIA
000000599550OtherANTHEM
000000599551OtherANTHEM NP
KY6434849300Medicaid
KY7570Medicare ID - Type Unspecified
000000599551OtherANTHEM NP
KY6434849300Medicaid