Basic Information
| Provider Information | |||||||||
| NPI: | 1972012615 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE HEALTH SERVICES, INC | ||||||||
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| OtherOrganizationName: | PHS GYN GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1160 VARNUM ST NE STE 102 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200172106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028544069 | ||||||||
| FaxNumber: | 2028547825 | ||||||||
| Practice Location | |||||||||
| Address1: | 1150 VARNUM ST NE | ||||||||
| Address2: | ST CATHERINE'S HALL, 2ND FLOOR | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200172107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028547074 | ||||||||
| FaxNumber: | 2028547470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2017 | ||||||||
| LastUpdateDate: | 10/11/2017 | ||||||||
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| AuthorizedOfficialLastName: | HIGGINBOTHAN | ||||||||
| 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 | 207VG0400X | HFD01-0212 | DC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
No ID Information.