Provider Demographics
NPI:1629160858
Name:POTOMAC PATHOLOGY CONSULTANTS INC
Entity Type:Organization
Organization Name:POTOMAC PATHOLOGY CONSULTANTS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HERNANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-264-1212
Mailing Address - Street 1:PO BOX 1295
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-1295
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-3402
Practice Address - Country:US
Practice Address - Phone:304-264-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207ZC0500X
WV10129207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0101738000 - IND.Medicaid
WVDG7831OtherRAILROAD MEDICARE
WV7900571 - GROUPMedicare PIN
WV7000921 - INDIVIDUALMedicare PIN