MEDICARE: PROGRESSIVE HABILITATIVE SERVICES, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	315P00000X	Intellectual Disabilities Intermediate Care Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164735817
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROGRESSIVE HABILITATIVE SERVICES, INC

Provider Business Mailing Address
First Line	:	13629 BALTIMORE AVE
Second Line	:
City	:	LAUREL
State	:	MD
Zip	:	20707-5095
Country	:	US
Telephone Number	:	301-317-9996
Fax Number	:	301-317-9988

Provider Business Practice Location Address
First Line	:	6405 CHILLUM PL NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20012-2133
Country	:	US
Telephone Number	:	202-545-0393
Fax Number	:	202-545-0392

Authorized Official
Title or Position	:	ACCOUNTS MANAGER
Name	:	RAMESH GUNDU
Credential	:
Telephone Number	:	301-317-9996

Provider Enumeration Date	:	07/23/2010
Last Update Date	:	09/23/2015

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