Provider Demographics
NPI:1184770117
Name:POTOMAC VALLEY SPORTS MEDICINE
Entity type:Organization
Organization Name:POTOMAC VALLEY SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELDON
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:MANDEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-774-0500
Mailing Address - Street 1:PO BOX 987
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20830-0987
Mailing Address - Country:US
Mailing Address - Phone:301-774-9300
Mailing Address - Fax:301-774-1186
Practice Address - Street 1:3414 OLANDWOOD CT
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1384
Practice Address - Country:US
Practice Address - Phone:301-774-0624
Practice Address - Fax:301-774-1186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCG01333Medicare PIN
DC709956Medicare PIN
MD376MMedicare PIN