Healthcare Provider Details

I. General information

NPI: 1669453809
Provider Name (Legal Business Name): PROVIDENCE HEALTH SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2005
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 VARNUM ST NE
WASHINGTON DC
20017-2107
US

IV. Provider business mailing address

1150 VARNUM ST NE ADMINISTRATION 4TH FLOOR
WASHINGTON DC
20017-2149
US

V. Phone/Fax

Practice location:
  • Phone: 202-854-7000
  • Fax: 202-269-7160
Mailing address:
  • Phone: 202-854-4255
  • Fax: 202-854-7160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberHFD01-0212
License Number StateDC
# 7
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. MITCHELL LOMAX
Title or Position: VICE PRESIDENT/CFO
Credential:
Phone: 667-234-2926