Provider Demographics
NPI:1083878730
Name:PHS CARE CENTER
Entity Type:Organization
Organization Name:PHS CARE CENTER
Other - Org Name:PROVIDENCE HEALTH SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:BEAU
Authorized Official - Middle Name:
Authorized Official - Last Name:HIGGINBOTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-368-3168
Mailing Address - Street 1:1160 VARNUM ST NE
Mailing Address - Street 2:ST CATHERINE'S HALL, ROOM 102
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2107
Mailing Address - Country:US
Mailing Address - Phone:202-854-4069
Mailing Address - Fax:202-854-7825
Practice Address - Street 1:1150 VARNUM ST NE
Practice Address - Street 2:SUITE 201
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2104
Practice Address - Country:US
Practice Address - Phone:202-854-7674
Practice Address - Fax:202-269-7825
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-11
Last Update Date:2017-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
DCHFD01-0212363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC023435100Medicaid
MD025501700Medicaid