Provider Demographics
NPI:1164775979
Name:POTOMAC HEALTHCARE ALLIANCE
Entity Type:Organization
Organization Name:POTOMAC HEALTHCARE ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:ESKEW
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:301-642-5390
Mailing Address - Street 1:198 THOMAS JOHNSON DR STE 5
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4449
Mailing Address - Country:US
Mailing Address - Phone:301-624-5390
Mailing Address - Fax:
Practice Address - Street 1:198 THOMAS JOHNSON DR STE 5
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4449
Practice Address - Country:US
Practice Address - Phone:301-624-5390
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD10554640261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1215171863OtherNPI
MD1720248198OtherNPI
MD1477595916OtherNPI
MD1477595916OtherNPI