MEDICARE: COMMONWEALTH NEONATOLOGY, INC.

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	2080N0001X	Neonatal-Perinatal Medicine Physician

General Provider Information

NPI Number	:	1922181007
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMONWEALTH NEONATOLOGY, INC.

Provider Business Mailing Address
First Line	:	412 LIBBIE AVE STE 4
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23226-2658
Country	:	US
Telephone Number	:	804-282-8082
Fax Number	:	804-282-9082

Provider Business Practice Location Address
First Line	:	412 LIBBIE AVE STE 4
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23226-2658
Country	:	US
Telephone Number	:	804-282-8082
Fax Number	:	804-282-9082

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BONITA JEAN MAKDAD
Credential	:	M.D.
Telephone Number	:	804-282-8082

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	08/22/2020

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