MEDICARE: POTOMAC PHYSICAL THERAPY 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
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1700184611
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POTOMAC PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	3010 CRAIN HWY
Second Line	:	SUITE 100
City	:	WALDORF
State	:	MD
Zip	:	20601-2801
Country	:	US
Telephone Number	:	301-567-8856
Fax Number	:

Provider Business Practice Location Address
First Line	:	3010 CRAIN HWY
Second Line	:	SUITE 100
City	:	WALDORF
State	:	MD
Zip	:	20601-2801
Country	:	US
Telephone Number	:	301-567-8856
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KEVIN RENEE COLVIN
Credential	:	DPT
Telephone Number	:	301-567-8856

Provider Enumeration Date	:	03/02/2011
Last Update Date	:	03/02/2011

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