Provider Demographics
NPI:1255336483
Name:POTOMAC FAMILY MEDICINE
Entity type:Organization
Organization Name:POTOMAC FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-791-7900
Mailing Address - Street 1:1324 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742
Mailing Address - Country:US
Mailing Address - Phone:301-791-7900
Mailing Address - Fax:301-791-3686
Practice Address - Street 1:13424 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742
Practice Address - Country:US
Practice Address - Phone:301-791-7900
Practice Address - Fax:301-791-3686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDNOT APPLICABLE207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS328OtherBLUECROSS/BLUESHIELD
MD599121800Medicaid
MD202589OtherFEDERAL BLACK LUNG PROGRA
MD599121800Medicaid