Provider Demographics
NPI:1427055359
Name:POTOMAC PEDAITRICS
Entity type:Organization
Organization Name:POTOMAC PEDAITRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:CAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-279-6750
Mailing Address - Street 1:9715 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 230
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3320
Mailing Address - Country:US
Mailing Address - Phone:301-279-6750
Mailing Address - Fax:301-279-6749
Practice Address - Street 1:9715 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 230
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3320
Practice Address - Country:US
Practice Address - Phone:301-279-6750
Practice Address - Fax:301-279-6749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0053781208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD=========OtherTAX ID