Provider Demographics
NPI:1144279076
Name:COMMONWEALTH GENERAL & VASCULAR SURGERY, P.C.
Entity type:Organization
Organization Name:COMMONWEALTH GENERAL & VASCULAR SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:POLIQUIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-330-5436
Mailing Address - Street 1:1401 JOHNSTON WILLIS DR
Mailing Address - Street 2:SUITE 5100
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235-4730
Mailing Address - Country:US
Mailing Address - Phone:804-330-5436
Mailing Address - Fax:804-560-0584
Practice Address - Street 1:1401 JOHNSTON WILLIS DR
Practice Address - Street 2:SUITE 5100
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235-4730
Practice Address - Country:US
Practice Address - Phone:804-330-5436
Practice Address - Fax:804-560-0584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033088174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
071139OtherANTHEM
4543869OtherAETNA PPO/MC
1013678OtherAETNA HMO
071139OtherANTHEM