Healthcare Provider Details

I. General information

NPI: 1790176170
Provider Name (Legal Business Name): POTOMAC VIEW ANESTHESIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2015
Last Update Date: 08/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6710 OXON HILL RD SUITE 150
OXON HILL MD
20745-1117
US

IV. Provider business mailing address

1302 RISING RIDGE RD SUITE 1
MOUNT AIRY MD
21771-5790
US

V. Phone/Fax

Practice location:
  • Phone: 301-829-7683
  • Fax: 301-829-7694
Mailing address:
  • Phone: 301-829-7683
  • Fax: 301-829-7694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: REZA IZADI
Title or Position: OWNER
Credential: DO
Phone: 301-829-7683