Healthcare Provider Details

I. General information

NPI: 1083158885
Provider Name (Legal Business Name): POTOMAC SPINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2016
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 KEY PKWY STE 103
FREDERICK MD
21702-4496
US

IV. Provider business mailing address

1050 KEY PKWY SUITE 202
FREDERICK MD
21702-4053
US

V. Phone/Fax

Practice location:
  • Phone: 240-629-3982
  • Fax:
Mailing address:
  • Phone: 240-629-3990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: KAL KAHLOON
Title or Position: CEO
Credential:
Phone: 240-629-3990