Basic Information
| Provider Information | |||||||||
| NPI: | 1881859817 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHS PROVIDENCE DIABETES AND NUTRITION CENTER | ||||||||
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| OtherOrganizationName: | PHS JOSLIN DIABETES CENTER DP110 | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1160 VARNUM ST NE | ||||||||
| Address2: | ST. CATHERINE'S HALL, ROOM 102 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200172107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028544069 | ||||||||
| FaxNumber: | 2028547825 | ||||||||
| Practice Location | |||||||||
| Address1: | 1160 VARNUM ST NE | ||||||||
| Address2: | DEPAUL 110 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200172107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028547123 | ||||||||
| FaxNumber: | 2028544854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2008 | ||||||||
| LastUpdateDate: | 10/09/2017 | ||||||||
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| AuthorizedOfficialLastName: | HIGGINBOTHAM | ||||||||
| AuthorizedOfficialFirstName: | BEAU | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT/COO | ||||||||
| AuthorizedOfficialTelephone: | 4103683162 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROVIDENCE HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | HFD01-0212 | DC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 133V00000X | HFD01-0212 | DC | Y | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 463400400 | 05 | MD | MEDICAID |