Provider Demographics
NPI:1013914951
Name:PRIMARY CARE ASSOCIATES OF POTOMAC PC
Entity type:Organization
Organization Name:PRIMARY CARE ASSOCIATES OF POTOMAC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-490-3997
Mailing Address - Street 1:1900 OPITZ BLVD
Mailing Address - Street 2:SUITE F
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191
Mailing Address - Country:US
Mailing Address - Phone:703-490-3997
Mailing Address - Fax:703-491-3376
Practice Address - Street 1:1900 OPITZ BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191
Practice Address - Country:US
Practice Address - Phone:703-490-3997
Practice Address - Fax:703-491-3376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101239629207R00000X
VA0101040884207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006064043Medicaid
B09548Medicare UPIN
VA110005661Medicare ID - Type Unspecified