Provider Demographics
NPI:1699081877
Name:COMMONWEALTH SPORT AND SPINE
Entity type:Organization
Organization Name:COMMONWEALTH SPORT AND SPINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:703-869-2229
Mailing Address - Street 1:PO BOX 651062
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20165-1062
Mailing Address - Country:US
Mailing Address - Phone:703-869-2229
Mailing Address - Fax:703-997-4322
Practice Address - Street 1:46165 WESTLAKE DR STE 100
Practice Address - Street 2:
Practice Address - City:POTOMAC FALLS
Practice Address - State:VA
Practice Address - Zip Code:20165-5872
Practice Address - Country:US
Practice Address - Phone:703-433-1700
Practice Address - Fax:703-433-9386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-25
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049657208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty