MEDICARE: COMMONWEALTH GASTROENTEROLOGY, PC

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	207RG0100X	Gastroenterology Physician

General Provider Information

NPI Number	:	1699403063
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMONWEALTH GASTROENTEROLOGY, PC

Provider Business Mailing Address
First Line	:	1215 N 26TH ST
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23223-5211
Country	:	US
Telephone Number	:	757-870-6595
Fax Number	:

Provider Business Practice Location Address
First Line	:	4000A GLENSIDE DR
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23228-4102
Country	:	US
Telephone Number	:	804-716-6318
Fax Number	:	804-801-5187

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	ERIN DALTON
Credential	:
Telephone Number	:	757-870-6595

Provider Enumeration Date	:	08/12/2022
Last Update Date	:	08/18/2022

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