Healthcare Provider Details

I. General information

NPI: 1598313595
Provider Name (Legal Business Name): PROVIDENCE HEALTH SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2019
Last Update Date: 05/06/2022
Certification Date: 05/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 VARNUM ST NE STE 1
WASHINGTON DC
20017-2104
US

IV. Provider business mailing address

1150 VARNUM ST NE
WASHINGTON DC
20017-2180
US

V. Phone/Fax

Practice location:
  • Phone: 202-854-7560
  • Fax: 202-854-7951
Mailing address:
  • Phone: 202-854-4069
  • Fax: 202-854-7825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL DUNWELL
Title or Position: COORD CREDENTIALING
Credential:
Phone: 202-854-4069