Provider Demographics
NPI:1376740449
Name:POTOMAC HEALTH SERVICES,LLC
Entity Type:Organization
Organization Name:POTOMAC HEALTH SERVICES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHAITRIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMUNA
Authorized Official - Middle Name:D
Authorized Official - Last Name:RAJU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-861-8722
Mailing Address - Street 1:6508 DEARBORN DR
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22044-1115
Mailing Address - Country:US
Mailing Address - Phone:703-658-8722
Mailing Address - Fax:
Practice Address - Street 1:611 S CARLIN SPRINGS RD
Practice Address - Street 2:SUITE # 501
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22204-1064
Practice Address - Country:US
Practice Address - Phone:703-861-8722
Practice Address - Fax:571-366-2056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-30
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236470101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00359381OtherMEDICARE RAILROAD
VAI25348Medicare UPIN
P00359381OtherMEDICARE RAILROAD