Provider Demographics
NPI:1467704890
Name:FRED E. POTTS, IV, MD, LLC
Entity Type:Organization
Organization Name:FRED E. POTTS, IV, MD, LLC
Other - Org Name:COVENANT PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:E
Authorized Official - Last Name:POTTS
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:816-233-3700
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-474-9809
Mailing Address - Fax:
Practice Address - Street 1:4906 FREDERICK AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3246
Practice Address - Country:US
Practice Address - Phone:816-233-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRED E. POTTS, IV, MD, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site