Healthcare Provider Details

I. General information

NPI: 1619245222
Provider Name (Legal Business Name): PROVIDENCE HEALTH SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2011
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 M ST NW
WASHINGTON DC
20001-1205
US

IV. Provider business mailing address

1150 VARNUM ST NE RM 407
WASHINGTON DC
20017-2180
US

V. Phone/Fax

Practice location:
  • Phone: 202-682-3840
  • Fax: 202-682-3854
Mailing address:
  • Phone: 202-854-4069
  • Fax: 202-854-7825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. BEAU HIGGINBOTHAM
Title or Position: VICE PRESIDENT/COO
Credential:
Phone: 410-638-3162