Basic Information
| Provider Information | |||||||||
| NPI: | 1881963544 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHS ORHTHOPAEDICS OLNEY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PROVIDENCE HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 18111 PRINCE PHILIP DR | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | OLNEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208321513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024484014 | ||||||||
| FaxNumber: | 2023720029 | ||||||||
| Practice Location | |||||||||
| Address1: | 18111 PRINCE PHILIP DR | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | OLNEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208321513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024484014 | ||||||||
| FaxNumber: | 2023720029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2011 | ||||||||
| LastUpdateDate: | 03/03/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | VIRGINIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR. VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2025344255 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROVIDENCE HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | HFD01-0212 | DC | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 09810714 | 05 | VA | MEDICAID | 005145400 | 05 | MD | MEDICAID | 029833400 | 05 | DC | MEDICAID |