Basic Information
Provider Information | |||||||||
NPI: | 1346235041 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMONWEALTH PRIMARY CARE, P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2 MERIDIAN BLVD | ||||||||
Address2: |   | ||||||||
City: | WYOMISSING | ||||||||
State: | PA | ||||||||
PostalCode: | 196103202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6103728257 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 805 N RICHMOND ST | ||||||||
Address2: |   | ||||||||
City: | FLEETWOOD | ||||||||
State: | PA | ||||||||
PostalCode: | 195221031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6109440464 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/19/2005 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HIPPERT | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | HEAD PHYSICIAN | ||||||||
AuthorizedOfficialTelephone: | 6109440464 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DO | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 03009300 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 488455 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | CI9844 | 01 | PA | PALMETTO GBA | OTHER |