=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447851720
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMONWEALTH PAIN ASSOCIATES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2020
-----------------------------------------------------
Last Update Date | 05/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 99 WELLPARK LN STE 4
-----------------------------------------------------
City | CAMPBELLSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42718-4919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-260-8613
-----------------------------------------------------
Fax | 859-977-2683
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 223 EXECUTIVE PARK
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40207-4202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-907-0356
-----------------------------------------------------
Fax | 502-919-9780
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JASON CARNES LEWIS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 502-855-3919
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------