Basic Information
| Provider Information | |||||||||
| NPI: | 1447869136 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POTOMAC SQUARE FAMILY MEDICINE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 173848 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802173848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039453299 | ||||||||
| FaxNumber: | 3033414708 | ||||||||
| Practice Location | |||||||||
| Address1: | 20270 E SMOKY HILL RD | ||||||||
| Address2: | |||||||||
| City: | CENTENNIAL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800153138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036932000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2020 | ||||||||
| LastUpdateDate: | 04/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | GLUCHACKI | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SVP, COMPLIANCE | ||||||||
| AuthorizedOfficialTelephone: | 5086899706 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 44008821 | 05 | CO | MEDICAID |