Provider Demographics
NPI:1073865093
Name:POTOMAC PEDIATRICS, P.C.
Entity Type:Organization
Organization Name:POTOMAC PEDIATRICS, P.C.
Other - Org Name:POTOMAC PEDIATRICS, SUITE 9
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARON
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-279-6750
Mailing Address - Street 1:6501 CITY WEST PKWY
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3248
Mailing Address - Country:US
Mailing Address - Phone:952-653-2525
Mailing Address - Fax:
Practice Address - Street 1:15204 OMEGA DR
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-4601
Practice Address - Country:US
Practice Address - Phone:301-279-6750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POTOMAC PEDIATRICS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site