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NPI Code Detail

MEDICARE: LYDIA POTOMA LLC

MEDICARE: LYDIA POTOMA LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12084P0800XPsychiatry Physician

General Provider Information

NPI Number : 1659177699
Entity Type Code : Organization
Provider Name (Legal Business Name) : LYDIA POTOMA LLC
Provider Business Mailing Address
First Line : 18051 JEFFERSON PARK RD STE 102
Second Line :
City : MIDDLEBURG HEIGHTS
State : OH
Zip : 44130-3460
Country : US
Telephone Number : 216-403-1291
Fax Number :
Provider Business Practice Location Address
First Line : 18051 JEFFERSON PARK RD STE 102
Second Line :
City : MIDDLEBURG HEIGHTS
State : OH
Zip : 44130-3460
Country : US
Telephone Number : 216-403-1291
Fax Number :
Authorized Official
Title or Position : OWNER
Name : LYDIA LEE POTOMA
Credential : MSN, APRN, CNP
Telephone Number : 216-403-1291
Provider Enumeration Date : 02/20/2025
Last Update Date : 02/20/2025

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Directions to “LYDIA POTOMA LLC ” Practice Location

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