1306345723 NPI number — COMMONWEALTH PAIN ASSOCIATES PLLC

Table of content: (NPI 1306345723)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306345723 NPI number — COMMONWEALTH PAIN ASSOCIATES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMONWEALTH PAIN ASSOCIATES PLLC
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:
Provider Other Organization Name Type Code:
6
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:
1306345723
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13000 EQUITY PL STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40223-3979
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-907-0356
Provider Business Mailing Address Fax Number:
502-919-9780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 THOMAS MORE PKWY STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRESTVIEW HILLS
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41017-3456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-331-0432
Provider Business Practice Location Address Fax Number:
859-331-0956
Provider Enumeration Date:
02/12/2018

Additional Information

Authorized Official

Authorized Official Last Name:
LEWIS
Authorized Official First Name:
JASON
Authorized Official Middle Name:
CARNES
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
502-855-3919

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100318140 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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