Provider Demographics
NPI:1619245222
Name:PROVIDENCE HEALTH SERVICES, INC
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH SERVICES, INC
Other - Org Name:PROVIDENCE HEALTH SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT/COO
Authorized Official - Prefix:MR
Authorized Official - First Name:BEAU
Authorized Official - Middle Name:
Authorized Official - Last Name:HIGGINBOTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-638-3162
Mailing Address - Street 1:1150 VARNUM ST NE RM 407
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 1:128 M ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-1205
Practice Address - Country:US
Practice Address - Phone:202-682-3840
Practice Address - Fax:202-682-3854
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-09
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
DCHFD01-0212282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No282N00000XHospitalsGeneral Acute Care HospitalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC023435102Medicaid
VA09810714Medicaid
DC029833400Medicaid
VA09810714Medicaid