Healthcare Provider Details

I. General information

NPI: 1962842401
Provider Name (Legal Business Name): PHS FAMILY MEDICINE GLENN DALE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2013
Last Update Date: 09/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12200 ANNAPOLIS RD SUITE 118
GLENN DALE MD
20769-9182
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: 301-464-9300
  • Fax: 202-854-4093
Mailing address:
  • Phone: 202-854-4069
  • Fax: 202-854-7825

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 Code282N00000X
TaxonomyGeneral Acute Care Hospital
License NumberHFD01-0212
License Number StateDC

VIII. Authorized Official

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