Healthcare Provider Details

I. General information

NPI: 1275651168
Provider Name (Legal Business Name): POTOMAC INTERNAL MEDICINE AND PEDIATRICS,LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 03/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 CENTENNIAL ST UNIT C-1
LA PLATA MD
20646-5967
US

IV. Provider business mailing address

PO BOX 1734
LA PLATA MD
20646-1734
US

V. Phone/Fax

Practice location:
  • Phone: 301-934-9711
  • Fax: 301-934-3998
Mailing address:
  • Phone: 301-934-9711
  • Fax: 301-934-3998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0052919
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0052919
License Number StateMD

VIII. Authorized Official

Name: DR. JAMES HARRING
Title or Position: MEDICAL DOCTOR
Credential: M.D.
Phone: 301-934-9711