1932310703 NPI number — POTOMAC RIVER CLINIC

Table of content: (NPI 1932310703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932310703 NPI number — POTOMAC RIVER CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POTOMAC RIVER CLINIC
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:
Provider Other Organization Name Type Code:
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:
1932310703
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4880 MACARTHUR BLVD NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
DC
Provider Business Mailing Address Postal Code:
20007-1557
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
202-333-1403
Provider Business Mailing Address Fax Number:
202-333-1404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4880 MACARTHUR BLVD NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20007-1557
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-333-1403
Provider Business Practice Location Address Fax Number:
202-333-1404
Provider Enumeration Date:
05/24/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
OUELLETTE
Authorized Official First Name:
MEREDITH
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT DIRECTOR
Authorized Official Telephone Number:
202-333-1403

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  2201001368 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 69161 . This is a "OPTIMA HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2532733 . This is a "AETNA HMO ID RICHMOND" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 353800 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 5500795 . This is a "AETNA ID PPO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1231037 . This is a "AETNA HMO ID# MCLEAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".