1013181791 NPI number — POTOMAC INOVA HEALTHCARE ALLIANCE

Table of content: (NPI 1013181791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013181791 NPI number — POTOMAC INOVA HEALTHCARE ALLIANCE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POTOMAC INOVA HEALTHCARE ALLIANCE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
POTOMAC RADIATION ONCOLOGY CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013181791
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2990 TELESTAR CT
Provider Second Line Business Mailing Address:
SUITE 3PI
Provider Business Mailing Address City Name:
FALLS CHURCH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22042-1207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
571-423-5727
Provider Business Mailing Address Fax Number:
571-423-5701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2296 OPITZ BLVD
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
WOODBRIDGE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22191-3300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-670-3349
Provider Business Practice Location Address Fax Number:
703-580-0730
Provider Enumeration Date:
04/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MASON
Authorized Official First Name:
JACKIE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
703-670-3349

Provider Taxonomy Codes

  • Taxonomy code: 261QX0203X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2521782 . This is a "AETNA HMO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 007603118 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2108004 . This is a "MAMSI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 245110 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 7154230 . This is a "AETNA PPO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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