Basic Information
| Provider Information | |||||||||
| NPI: | 1194985515 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE HEALTH SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1150 VARNUM ST NE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200172149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2022697286 | ||||||||
| FaxNumber: | 2022697825 | ||||||||
| Practice Location | |||||||||
| Address1: | 4151 BLADENSBURG RD | ||||||||
| Address2: | |||||||||
| City: | COLMAR MANOR | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207221928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016997700 | ||||||||
| FaxNumber: | 3017799001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2008 | ||||||||
| LastUpdateDate: | 10/09/2017 | ||||||||
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| AuthorizedOfficialLastName: | SHERIDAN | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSISTANT VP, PRACTICE MGT SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 2022697374 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROVIDENCE HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | HFD01-0212 | DC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | HFD01-0212 | DC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 548521501 | 05 | MD | MEDICAID |