Provider Demographics
NPI:1407923519
Name:POTTSTOWN CLINIC COMPANY, LLC
Entity Type:Organization
Organization Name:POTTSTOWN CLINIC COMPANY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-892-9813
Mailing Address - Street 1:730 S HANOVER ST
Mailing Address - Street 2:
Mailing Address - City:POTTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19465-7520
Mailing Address - Country:US
Mailing Address - Phone:610-323-6835
Mailing Address - Fax:610-323-4154
Practice Address - Street 1:730 S HANOVER ST
Practice Address - Street 2:
Practice Address - City:POTTSTOWN
Practice Address - State:PA
Practice Address - Zip Code:19465-7520
Practice Address - Country:US
Practice Address - Phone:610-323-6835
Practice Address - Fax:610-323-4154
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POTTSTOWN CLINIC COMPANY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-30
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA=========OtherTAX ID