Basic Information
| Provider Information | |||||||||
| NPI: | 1962058214 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAINT ELIZABETHS HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1349 KENYON ST NW APT 44 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200102346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2405478653 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1100 ALABAMA AVE SE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200324542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2022995100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2019 | ||||||||
| LastUpdateDate: | 01/24/2020 | ||||||||
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| AuthorizedOfficialLastName: | HALL | ||||||||
| AuthorizedOfficialFirstName: | BERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | ATTENDING DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 2022995100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | 01/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.