Provider Demographics
NPI:1376735100
Name:EDGER V POTTER JR MD INC
Entity type:Organization
Organization Name:EDGER V POTTER JR MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDGER
Authorized Official - Middle Name:VERDAN
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:301-203-9570
Mailing Address - Street 1:12017 FORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-6004
Mailing Address - Country:US
Mailing Address - Phone:301-203-9570
Mailing Address - Fax:301-203-1796
Practice Address - Street 1:12017 FORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-6004
Practice Address - Country:US
Practice Address - Phone:301-203-9570
Practice Address - Fax:301-203-1796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD9565207QG0300X, 207RR0500X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC023634400Medicaid
MD260891000Medicaid
DCB94575Medicare UPIN
DC723077Medicare PIN