Provider Demographics
NPI:1598313595
Name:PROVIDENCE HEALTH SERVICES, INC
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH SERVICES, INC
Other - Org Name:THE PROVIDENCE DIAGNOSTIC IMAGING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COORD CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-854-4069
Mailing Address - Street 1:1150 VARNUM ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2180
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 1
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2104
Practice Address - Country:US
Practice Address - Phone:202-854-7560
Practice Address - Fax:202-854-7951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-03
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
No335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier