Provider Demographics
NPI:1356859334
Name:PROVIDENCE HEALTH SERVICES, INC
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH SERVICES, INC
Other - Org Name:PHS CARDIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT/COO
Authorized Official - Prefix:
Authorized Official - First Name:BEAU
Authorized Official - Middle Name:
Authorized Official - Last Name:HIGGINBOTHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-368-3182
Mailing Address - Street 1:1150 VARNUM ST NE
Mailing Address - Street 2:ST CATHERINES HALL, ROOM 102
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2104
Mailing Address - Country:US
Mailing Address - Phone:202-854-4069
Mailing Address - Fax:202-854-7825
Practice Address - Street 1:1150 VARNUM ST NE STE 300
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2180
Practice Address - Country:US
Practice Address - Phone:202-854-4830
Practice Address - Fax:202-854-4836
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-01-12
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHFD01-0212174400000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty