Healthcare Provider Details

I. General information

NPI: 1134584667
Provider Name (Legal Business Name): PROVIDENCE HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2015
Last Update Date: 12/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3413 OLIVE BRANCH DR
SILVER SPRING MD
20904-4973
US

IV. Provider business mailing address

1150 VARNUM ST NE
WAHINGTON DC DC
20017
US

V. Phone/Fax

Practice location:
  • Phone: 301-256-7630
  • Fax:
Mailing address:
  • Phone: 202-854-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberRN1014643
License Number StateDC

VIII. Authorized Official

Name: YIESAK ASFAW
Title or Position: NP
Credential:
Phone: 301-256-7630