=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750659272
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHS FAMILY MEDICINE & PEDIATRICS PMB103
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2011
-----------------------------------------------------
Last Update Date | 09/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1140 VARNUM ST NE PMB103
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20017-2151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-854-7074
-----------------------------------------------------
Fax | 202-854-7470
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1160 VARNUM ST NE ST CATHERINE'S HALL, ROOM 102
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20017-2107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-854-4069
-----------------------------------------------------
Fax | 202-854-7825
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP
-----------------------------------------------------
Name | MR. CHARLES F HABERKERN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 202-854-4255
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | HFD01-0212
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | HFD01-0212
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | HFD01-0212
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------