Potomac Hospital Corporation of Prince William

Primary specialty

Clinic/CenterTaxonomy code 261Q00000X

Legal business name

POTOMAC HOSPITAL CORPORATION OF PRINCE WILLIAM

Doing business as

Lake Ridge

Practice address

12825 Minnieville Road
Lake Ridge, VA 22192-9998

Phone

(703) 523-9800

NPI assigned

Mar 26, 2012

Last updated

Mar 26, 2012By the provider in NPPES

Organization subpart

Yes

Parent organization

SENTARA HEALTHCAREAs reported in NPPES

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Robert A Broermann

Title

SVP/Cfo

Phone

(757) 455-7020

Specialties & licenses 1

Addresses

Other names 1

• Lake Ridge Doing business as

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Tax ID family

PFH Lake Ridge Potomac3 organizations share this tax ID, including this one

Part of

Port Warwick Medical Arts

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

• Potomac Hospital

  • Obstetrics & Gynecology Physician
  • Woodbridge, VA
  • NPI 1447398581
  NPD tax ID
• Potomac Hospital Corporation of Prince William

  • Community/Retail Pharmacy
  • Woodbridge, VA
  • NPI 1013865013
  NPD tax ID

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

• Sentara Healthcare

  • General Acute Care Hospital
  • Hampton, VA
  • NPI 1730615816
  NPPES parent name

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1332720000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1332720000000",
    "number": "1366718215",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12825 MINNIEVILLE ROAD",
            "city": "LAKE RIDGE",
            "state": "VA",
            "postal_code": "221929998",
            "telephone_number": "703-523-9800"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12825 MINNIEVILLE ROAD",
            "city": "LAKE RIDGE",
            "state": "VA",
            "postal_code": "221929998",
            "telephone_number": "703-523-9800"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "POTOMAC HOSPITAL CORPORATION OF PRINCE WILLIAM",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SENTARA HEALTHCARE",
        "enumeration_date": "2012-03-26",
        "last_updated": "2012-03-26",
        "status": "A",
        "authorized_official_last_name": "BROERMANN",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "SVP/CFO",
        "authorized_official_telephone_number": "757-455-7020",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "VA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lake Ridge",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Patient First Richmond Medical Group PLLC (Patient First - Lake Ridge)
• Patriot Home Care Services, LLC
• Taryn Nichelle Pettigrew, OT
• Andrew Davis Pfaff, PA-C
• Jonathan Phuong
• Donna L Price, LPC
• Jun Anthony V Quion, M.D. FACC
• Michelle Rainville
• Rehab Masters, Inc.
• Jennifer Regenia Rivers, LPC

• Clinic/Center in Lake Ridge, VA
• Providers in Lake Ridge, VA by specialty
• Clinic/Center in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 26, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.