Healthcare Provider Details

I. General information

NPI: 1396012837
Provider Name (Legal Business Name): PHS BEHAVIORAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2011
Last Update Date: 09/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1053 BUCHANAN ST NE SUITE 055
WASHINGTON DC
20017-2712
US

IV. Provider business mailing address

1150 VARNUM ST NE ST CATHERINE'S HALL, ROOM 102
WASHINGTON DC
20017-2104
US

V. Phone/Fax

Practice location:
  • Phone: 202-269-7626
  • Fax: 202-269-7616
Mailing address:
  • Phone: 202-854-4069
  • Fax: 202-854-7825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberHFD01-0212
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberHFD01-0212
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License NumberHFD01-0112
License Number StateDC

VIII. Authorized Official

Name: MR. CHARLES F HABERKERN
Title or Position: VP
Credential:
Phone: 202-854-4255