Provider Demographics
NPI:1710151402
Name:POTOMAC INOVA HEALTHCARE ALLIANCE, LLC
Entity Type:Organization
Organization Name:POTOMAC INOVA HEALTHCARE ALLIANCE, LLC
Other - Org Name:WOODBRIDGE CT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROJECT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HUELSKAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-204-6371
Mailing Address - Street 1:2990 TELESTAR CT
Mailing Address - Street 2:SUITE 3PI
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1207
Mailing Address - Country:US
Mailing Address - Phone:571-423-5727
Mailing Address - Fax:571-423-5702
Practice Address - Street 1:4001 PRINCE WILLIAM PKWY
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-7630
Practice Address - Country:US
Practice Address - Phone:703-494-3309
Practice Address - Fax:703-357-9636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA344745OtherANTHEM