Provider Demographics
NPI:1982810016
Name:POTOMAC VILLAGE FAMILY PRACTICE PC
Entity Type:Organization
Organization Name:POTOMAC VILLAGE FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CHANDLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-494-1028
Mailing Address - Street 1:2010 OPITZ BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3359
Mailing Address - Country:US
Mailing Address - Phone:703-494-1028
Mailing Address - Fax:
Practice Address - Street 1:2010 OPITZ BLVD STE A
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3359
Practice Address - Country:US
Practice Address - Phone:703-494-1028
Practice Address - Fax:703-494-0445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA07L15218207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5676410Medicaid
VI036099OtherANTHEM BLUE CROSS
VI036099OtherANTHEM BLUE CROSS