Healthcare Provider Details

I. General information

NPI: 1215124870
Provider Name (Legal Business Name): COMMONWEALTH PAIN SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 01/31/2020
Certification Date: 01/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 MAPLE AVENUE SUITE 301
RICHMOND VA
23229
US

IV. Provider business mailing address

PO BOX 8310
ROANOKE VA
24014-0310
US

V. Phone/Fax

Practice location:
  • Phone: 804-288-7246
  • Fax: 804-288-7245
Mailing address:
  • Phone: 540-345-3556
  • Fax: 540-342-2193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number0101043055
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. STEPHEN P LONG
Title or Position: MEDICAL DIRECTOR/PARTNER
Credential: MD
Phone: 804-288-7246