Healthcare Provider Details

I. General information

NPI: 1134598394
Provider Name (Legal Business Name): PHS MULTISPECIALTY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2015
Last Update Date: 10/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14300 GALLANT FOX LN SUITE 224
BOWIE MD
20715-4003
US

IV. Provider business mailing address

1160 VARNUM ST NE ST CATHERINE'S HALL, ROOM 102
WASHINGTON DC
20017-2107
US

V. Phone/Fax

Practice location:
  • Phone: 301-262-8291
  • Fax: 301-262-7740
Mailing address:
  • Phone: 202-854-4069
  • Fax: 202-854-7825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberHFD01-0212
License Number StateDC

VIII. Authorized Official

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