Healthcare Provider Details

I. General information

NPI: 1356859334
Provider Name (Legal Business Name): PROVIDENCE HEALTH SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2018
Last Update Date: 01/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 VARNUM ST NE STE 300
WASHINGTON DC
20017-2180
US

IV. Provider business mailing address

1150 VARNUM ST NE ST CATHERINES HALL, ROOM 102
WASHINGTON DC
20017-2104
US

V. Phone/Fax

Practice location:
  • Phone: 202-854-4830
  • Fax: 202-854-4836
Mailing address:
  • Phone: 202-854-4069
  • Fax: 202-854-7825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberHFD01-0212
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberHFD01-0212
License Number StateDC

VIII. Authorized Official

Name: BEAU HIGGINBOTHAN
Title or Position: VICE PRESIDENT/COO
Credential:
Phone: 410-368-3182