Healthcare Provider Details

I. General information

NPI: 1649232026
Provider Name (Legal Business Name): COMMONWEALTH INFECTIOUS DISEASE PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3910 S DUPONT SQ SUITE A
LOUISVILLE KY
40207-4615
US

IV. Provider business mailing address

PO BOX 32172
LOUISVILLE KY
40232-2172
US

V. Phone/Fax

Practice location:
  • Phone: 502-896-8299
  • Fax:
Mailing address:
  • Phone: 502-896-8299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number33270
License Number StateKY

VIII. Authorized Official

Name: ERIC XIA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 812-948-5159