Healthcare Provider Details

I. General information

NPI: 1831467356
Provider Name (Legal Business Name): PHS CENTER FOR LIFE SC 2ND FLOOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 VARNUM ST NE ST. CATHERINE'S HALL, 2ND FLOOR
WASHINGTON DC
20017-2107
US

IV. Provider business mailing address

1150 VARNUM ST NE RM 102
WASHINGTON DC
20017-2104
US

V. Phone/Fax

Practice location:
  • Phone: 202-269-7074
  • Fax: 202-372-0026
Mailing address:
  • Phone: 202-854-7074
  • Fax: 202-854-7825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License NumberHFD01-0212
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberHFD01-0212
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberHFD01-0212
License Number StateDC

VIII. Authorized Official

Name: MR. BEAU HIGGINBOTHAM
Title or Position: VP
Credential:
Phone: 410-368-3162