Provider Demographics
NPI:1326316936
Name:PHS INTERNAL MEDICINE PMB202
Entity Type:Organization
Organization Name:PHS INTERNAL MEDICINE PMB202
Other - Org Name:PROVIDENCE HEALTH SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:F
Authorized Official - Last Name:HABERKERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-854-4255
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 1:1140 VARNUM ST NE
Practice Address - Street 2:PMB 202
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2151
Practice Address - Country:US
Practice Address - Phone:202-854-4242
Practice Address - Fax:202-854-4245
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-09
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHFD01-0212207R00000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No282N00000XHospitalsGeneral Acute Care HospitalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD005145400Medicaid
VA09810714Medicaid
DC029833400Medicaid
090006Medicare PIN