MEDICARE: COMMONWEALTH MEDICAL CORP

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1942698345
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMONWEALTH MEDICAL CORP

Provider Business Mailing Address
First Line	:	5210 S MIDDLEBROOK PIKE
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37921-5972
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2427 PINEY GROVE CHURCH RD
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37921-3765
Country	:	US
Telephone Number	:	865-936-5635
Fax Number	:	865-622-3885

Authorized Official
Title or Position	:	INFRASTRUCTURE AND DESIGN CONCEPTS
Name	:	THEO S STEPHENS
Credential	:
Telephone Number	:	865-936-5635

Provider Enumeration Date	:	01/07/2015
Last Update Date	:	01/07/2015

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