Provider Demographics
NPI:1740235548
Name:POTOMAC SQUARE FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:POTOMAC SQUARE FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP, COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GLUCHACKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-689-9706
Mailing Address - Street 1:PO BOX 173848
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-3848
Mailing Address - Country:US
Mailing Address - Phone:303-945-3299
Mailing Address - Fax:303-341-4708
Practice Address - Street 1:13650 E MISSISSIPPI AVE STE 110
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-3573
Practice Address - Country:US
Practice Address - Phone:303-695-8684
Practice Address - Fax:303-597-0191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X, 261QP2300X
CO140650163W00000X, 207Q00000X
CO163W00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO77404343Medicaid
CO542158Medicare ID - Type Unspecified
CO542158Medicare ID - Type Unspecified