Basic Information
| Provider Information | |||||||||
| NPI: | 1972615656 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE CARDIOLOGY ASSOCIATES, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 BERWYN HOUSE RD | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | COLLEGE PARK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012200150 | ||||||||
| FaxNumber: | 3012201032 | ||||||||
| Practice Location | |||||||||
| Address1: | 1150 VARNUM ST NE | ||||||||
| Address2: | PROVIDENCE HOSPITAL | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 20017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2022697118 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 09/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | LOIS | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3012200150 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 024607200 | 05 | DC | MEDICAID |