Healthcare Provider Details

I. General information

NPI: 1689005720
Provider Name (Legal Business Name): PROVIDENCE HEALTH SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2013
Last Update Date: 10/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 VARNUM ST NE DEPAUL 312
WASHINGTON DC
20017-2107
US

IV. Provider business mailing address

PO BOX 418893
BOSTON MA
02241-8893
US

V. Phone/Fax

Practice location:
  • Phone: 202-534-4400
  • Fax: 202-435-4412
Mailing address:
  • Phone: 202-448-4069
  • Fax: 202-269-7825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberHFD01-0212
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License NumberHFD01-0212
License Number StateDC

VIII. Authorized Official

Name: BEAU HIGGINBOTHAM
Title or Position: VICE PRESIDENT/COO
Credential:
Phone: 410-368-3162