Provider Demographics
NPI:1831112143
Name:POTOMAC PHYSICIAN ASSOCIATES
Entity Type:Organization
Organization Name:POTOMAC PHYSICIAN ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-493-4440
Mailing Address - Street 1:10215 FERNWOOD RD
Mailing Address - Street 2:STE 100
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817-1106
Mailing Address - Country:US
Mailing Address - Phone:301-493-4440
Mailing Address - Fax:301-493-9778
Practice Address - Street 1:8401 CONNECTICUT AVE PH SUITE
Practice Address - Street 2:
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-5822
Practice Address - Country:US
Practice Address - Phone:301-942-2212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC808745Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER