Basic Information
| Provider Information | |||||||||
| NPI: | 1225228059 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMONWEALTH SURGICAL SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1945 SCOTTSVILLE RD | ||||||||
| Address2: | B2 PMB137 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421043376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707820434 | ||||||||
| FaxNumber: | 2707820564 | ||||||||
| Practice Location | |||||||||
| Address1: | 1725 ASHLEY CIR STE 211 | ||||||||
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| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421045820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707820434 | ||||||||
| FaxNumber: | 2707820564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2007 | ||||||||
| LastUpdateDate: | 07/27/2007 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2707820434 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.