Healthcare Provider Details

I. General information

NPI: 1255336483
Provider Name (Legal Business Name): POTOMAC FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13424 PENNSYLVANIA AVE SUITE 101
HAGERSTOWN MD
21742
US

IV. Provider business mailing address

1324 PENNSYLVANIA AVE SUITE 101
HAGERSTOWN MD
21742
US

V. Phone/Fax

Practice location:
  • Phone: 301-791-7900
  • Fax: 301-791-3686
Mailing address:
  • Phone: 301-791-7900
  • Fax: 301-791-3686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberNOT APPLICABLE
License Number StateMD

VIII. Authorized Official

Name: MRS. DEBORAH R LEE
Title or Position: PRACTICE MANAGER
Credential:
Phone: 301-791-7900