Healthcare Provider Details

I. General information

NPI: 1790706844
Provider Name (Legal Business Name): POTOMAC PHYSICIANS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 11/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9649 BELAIR RD SECOND FLOOR
BALTIMORE MD
21236-1100
US

IV. Provider business mailing address

9649 BELAIR RD SECOND FLOOR
BALTIMORE MD
21236-1100
US

V. Phone/Fax

Practice location:
  • Phone: 410-248-2650
  • Fax: 410-248-2657
Mailing address:
  • Phone: 410-248-2650
  • Fax: 410-248-2657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CAROL REYNOLDS
Title or Position: PRESIDENTMEDICAL DIRECTOR
Credential: M.D.
Phone: 410-248-2650