MEDICARE: COMMONWEALTH FAMILY PRACTICE LTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	0102037160	VA
2	208D00000X	General Practice Physician	0102037170	VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	H9571	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	287512	OTHER	BLUE CROSS
2	287512	OTHER	BLUE CROSS-BLUE SHIELD
3	318871	OTHER	BLUE CROSS/BLUE SHIELD
5	318871	OTHER	BLUE CROSS

General Provider Information

NPI Number	:	1215936547
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMONWEALTH FAMILY PRACTICE LTD

Provider Business Mailing Address
First Line	:	10201 KRAUSE RD
Second Line	:
City	:	CHESTERFIELD
State	:	VA
Zip	:	23832-6575
Country	:	US
Telephone Number	:	804-748-6229
Fax Number	:	804-748-5909

Provider Business Practice Location Address
First Line	:	10201 KRAUSE RD
Second Line	:
City	:	CHESTERFIELD
State	:	VA
Zip	:	23832-6575
Country	:	US
Telephone Number	:	804-748-6229
Fax Number	:	804-748-5909

Authorized Official
Title or Position	:	VICE PRESIDENT CEO
Name	:	DR. MARIANNE LAND SIEGRIST
Credential	:	DO
Telephone Number	:	804-748-6229

Provider Enumeration Date	:	07/19/2005
Last Update Date	:	04/20/2008

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Directions to “COMMONWEALTH FAMILY PRACTICE LTD ” Practice Location

Language	Start Address	Practice Location

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