1215124870 NPI number — COMMONWEALTH PAIN SPECIALISTS, LLC

Table of content: (NPI 1215124870)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215124870 NPI number — COMMONWEALTH PAIN SPECIALISTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMONWEALTH PAIN SPECIALISTS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COMMONWEALTH PAIN SPECIALISTS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215124870
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8310
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24014-0310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-345-3556
Provider Business Mailing Address Fax Number:
540-342-2193

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 MAPLE AVENUE
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-288-7246
Provider Business Practice Location Address Fax Number:
804-288-7245
Provider Enumeration Date:
09/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LONG
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
P
Authorized Official Title or Position:
MEDICAL DIRECTOR/PARTNER
Authorized Official Telephone Number:
804-288-7246

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  0101043055 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CH0711 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 431692 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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