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General NPI Number Information
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NPI Number | 1720190390
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Entity Type | Organization
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Legal Business Name | COMMONWEALTH EAR, NOSE & THROAT SPECIALISTS PC
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 07/14/2010
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Provider Practice Location Address
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Address Line | 14051 ST FRANCIS BLVD SUITE 2211
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City | MIDLOTHIAN
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State | VA
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Zip | 23114-3201
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Country | US
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Telephone | 540-345-3556
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Fax | 540-342-2193
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Provider Business Mailing Address
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Address Line | PO BOX 8310
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City | ROANOKE
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State | VA
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Zip | 24014-0310
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Country | US
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Telephone | 540-345-3556
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Fax | 540-342-2193
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Authorized Official
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Title or Position | PRESIDENT
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Name | PATRICK J GIBBONS
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Credential | M.D.
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Telephone | 540-345-3556
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | 010122975
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License Number State | VA
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