Provider Demographics
NPI:1548083371
Name:POTOMAC HEALTH OF MINNESOTA
Entity type:Organization
Organization Name:POTOMAC HEALTH OF MINNESOTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KIMMEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-728-6740
Mailing Address - Street 1:1177 HIGH RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-1221
Mailing Address - Country:US
Mailing Address - Phone:860-259-4992
Mailing Address - Fax:
Practice Address - Street 1:1177 HIGH RIDGE RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-1221
Practice Address - Country:US
Practice Address - Phone:860-259-4992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POTOMAC HEALTH PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-10-31
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty