Basic Information
| Provider Information | |||||||||
| NPI: | 1689005720 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE HEALTH SERVICES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 418893 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022418893 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024484069 | ||||||||
| FaxNumber: | 2022697825 | ||||||||
| Practice Location | |||||||||
| Address1: | 1160 VARNUM ST NE | ||||||||
| Address2: | DEPAUL 312 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200172107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2025344400 | ||||||||
| FaxNumber: | 2024354412 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2013 | ||||||||
| LastUpdateDate: | 10/09/2017 | ||||||||
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| AuthorizedOfficialLastName: | HIGGINBOTHAM | ||||||||
| AuthorizedOfficialFirstName: | BEAU | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT/COO | ||||||||
| AuthorizedOfficialTelephone: | 4103683162 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROVIDENCE HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | HFD01-0212 | DC | N | Hospitals | General Acute Care Hospital | 207XX0005X | HFD01-0212 | DC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No ID Information.