Provider Demographics
NPI:1285850479
Name:POTOMAC PAIN AND REHABILITATION ASSOCIATES, LLC
Entity Type:Organization
Organization Name:POTOMAC PAIN AND REHABILITATION ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FADIL
Authorized Official - Middle Name:AJAY
Authorized Official - Last Name:YUNIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-934-2776
Mailing Address - Street 1:PO BOX 2540
Mailing Address - Street 2:203 CENTENNIAL ST SUITE 104
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-2540
Mailing Address - Country:US
Mailing Address - Phone:301-934-2776
Mailing Address - Fax:301-934-1417
Practice Address - Street 1:203 CENTENNIAL ST SUITE 104
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-2540
Practice Address - Country:US
Practice Address - Phone:301-934-2776
Practice Address - Fax:301-934-1417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD512006300Medicaid
MD512006300Medicaid