Basic Information
| Provider Information | |||||||||
| NPI: | 1962842401 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHS FAMILY MEDICINE GLENN DALE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROVIDENCE HEALTH SERVICES, INC | ||||||||
| 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: | 12200 ANNAPOLIS RD | ||||||||
| Address2: | SUITE 118 | ||||||||
| City: | GLENN DALE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207699182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014649300 | ||||||||
| FaxNumber: | 2028544093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2013 | ||||||||
| LastUpdateDate: | 09/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | HABERKERN | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 2028544255 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROVIDENCE HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | HFD01-0212 | DC | N | Hospitals | General Acute Care Hospital | 207Q00000X | HFD01-0212 | DC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 029833400 | 05 | DC | MEDICAID | 09810714 | 05 | VA | MEDICAID | 005145400 | 05 | MD | MEDICAID |