Basic Information
| Provider Information | |||||||||
| NPI: | 1609485382 | ||||||||
| 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: | 730 W HAMPDEN AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801102129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7209747466 | ||||||||
| FaxNumber: | 3039537274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2020 | ||||||||
| LastUpdateDate: | 09/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | SWITZER | ||||||||
| AuthorizedOfficialFirstName: | TRESA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CORPORATE CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 3033414730 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/15/2020 | ||||||||
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 | 91425859 | 05 | CO | MEDICAID |