Healthcare Provider Details

I. General information

NPI: 1194985515
Provider Name (Legal Business Name): PROVIDENCE HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 10/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4151 BLADENSBURG RD
COLMAR MANOR MD
20722-1928
US

IV. Provider business mailing address

1150 VARNUM ST NE
WASHINGTON DC
20017-2149
US

V. Phone/Fax

Practice location:
  • Phone: 301-699-7700
  • Fax: 301-779-9001
Mailing address:
  • Phone: 202-269-7286
  • Fax: 202-269-7825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberHFD01-0212
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberHFD01-0212
License Number StateDC

VIII. Authorized Official

Name: TIMOTHY SHERIDAN
Title or Position: ASSISTANT VP, PRACTICE MGT SERVICES
Credential:
Phone: 202-269-7374