Provider Demographics
NPI:1932310703
Name:POTOMAC RIVER CLINIC
Entity Type:Organization
Organization Name:POTOMAC RIVER CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MEREDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:OUELLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-333-1403
Mailing Address - Street 1:4880 MACARTHUR BLVD NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20007-1557
Mailing Address - Country:US
Mailing Address - Phone:202-333-1403
Mailing Address - Fax:202-333-1404
Practice Address - Street 1:4880 MACARTHUR BLVD NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007-1557
Practice Address - Country:US
Practice Address - Phone:202-333-1403
Practice Address - Fax:202-333-1404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2201001368231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA69161OtherOPTIMA HEALTH
VA2532733OtherAETNA HMO ID RICHMOND
VA353800OtherANTHEM BC/BS
VA5500795OtherAETNA ID PPO
VA1231037OtherAETNA HMO ID# MCLEAN
VA69161OtherOPTIMA HEALTH