Healthcare Provider Details

I. General information

NPI: 1306455092
Provider Name (Legal Business Name): POTOMAC SQUARE FAMILY MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 04/15/2022
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6080 W 92ND AVE STE 1000
WESTMINSTER CO
80031-2935
US

IV. Provider business mailing address

PO BOX 173848
DENVER CO
80217-3848
US

V. Phone/Fax

Practice location:
  • Phone: 303-427-0796
  • Fax:
Mailing address:
  • Phone: 303-945-3299
  • Fax: 303-945-3303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE GLUCHACKI
Title or Position: SVP, COMPLIANCE
Credential:
Phone: 508-689-9706