Healthcare Provider Details

I. General information

NPI: 1689397739
Provider Name (Legal Business Name): POTOMAC INSTITUTE OF PAIN MANAGEMENT AND PALLIATIVE CARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2022
Last Update Date: 09/23/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8435 PROGRESS DR STE EE
FREDERICK MD
21701-4981
US

IV. Provider business mailing address

8435 PROGRESS DR STE EE
FREDERICK MD
21701-4981
US

V. Phone/Fax

Practice location:
  • Phone: 301-624-5390
  • Fax:
Mailing address:
  • Phone: 301-624-5390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GLORIA CORBIN
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 301-732-6300