Provider Demographics
NPI:1083158885
Name:POTOMAC SPINE, LLC
Entity type:Organization
Organization Name:POTOMAC SPINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KAL
Authorized Official - Middle Name:
Authorized Official - Last Name:KAHLOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-629-3990
Mailing Address - Street 1:1050 KEY PKWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4053
Mailing Address - Country:US
Mailing Address - Phone:240-629-3990
Mailing Address - Fax:
Practice Address - Street 1:1050 KEY PKWY STE 103
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4496
Practice Address - Country:US
Practice Address - Phone:240-629-3982
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty