Provider Demographics
NPI:1548366404
Name:POTOMAC HOSPITAL CORPORATION OF PRINCE WILLIAM
Entity type:Organization
Organization Name:POTOMAC HOSPITAL CORPORATION OF PRINCE WILLIAM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SVP/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROERMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-455-7020
Mailing Address - Street 1:2300 OPITZ BLVD
Mailing Address - Street 2:PATIENT FINANCIAL SERVICES
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3311
Mailing Address - Country:US
Mailing Address - Phone:703-670-1595
Mailing Address - Fax:703-670-3267
Practice Address - Street 1:2300 OPITZ BLVD
Practice Address - Street 2:PATIENT FINANCIAL SERVICES
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3311
Practice Address - Country:US
Practice Address - Phone:703-670-1595
Practice Address - Fax:703-670-3267
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SENTARA HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-16
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAH1771282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA000028OtherANTHEM BCBS
VA293165OtherANTHEM HCFA
VA4901134Medicaid
VAC00500Medicare PIN
VA293165OtherANTHEM HCFA
VA490113Medicare Oscar/Certification