Provider Demographics
NPI:1013181791
Name:POTOMAC INOVA HEALTHCARE ALLIANCE
Entity Type:Organization
Organization Name:POTOMAC INOVA HEALTHCARE ALLIANCE
Other - Org Name:POTOMAC RADIATION ONCOLOGY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-670-3349
Mailing Address - Street 1:2990 TELESTAR CT
Mailing Address - Street 2:SUITE 3PI
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1207
Mailing Address - Country:US
Mailing Address - Phone:571-423-5727
Mailing Address - Fax:571-423-5701
Practice Address - Street 1:2296 OPITZ BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3300
Practice Address - Country:US
Practice Address - Phone:703-670-3349
Practice Address - Fax:703-580-0730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, Radiation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2521782OtherAETNA HMO
VA007603118Medicaid
VA2108004OtherMAMSI
VA245110OtherANTHEM
VA7154230OtherAETNA PPO
VA007603118Medicaid