Basic Information
| Provider Information | |||||||||
| NPI: | 1619245222 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE HEALTH SERVICES, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROVIDENCE HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1150 VARNUM ST NE RM 407 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200172180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028544069 | ||||||||
| FaxNumber: | 2028547825 | ||||||||
| Practice Location | |||||||||
| Address1: | 128 M ST NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200011205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2026823840 | ||||||||
| FaxNumber: | 2026823854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2011 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HIGGINBOTHAM | ||||||||
| AuthorizedOfficialFirstName: | BEAU | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT/COO | ||||||||
| AuthorizedOfficialTelephone: | 4106383162 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROVIDENCE HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 023435102 | 05 | DC | MEDICAID |