Provider Demographics
NPI:1881859817
Name:PHS PROVIDENCE DIABETES AND NUTRITION CENTER
Entity Type:Organization
Organization Name:PHS PROVIDENCE DIABETES AND NUTRITION CENTER
Other - Org Name:PHS JOSLIN DIABETES CENTER DP110
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT/COO
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:410-368-3162
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 1:1160 VARNUM ST NE
Practice Address - Street 2:DEPAUL 110
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2107
Practice Address - Country:US
Practice Address - Phone:202-854-7123
Practice Address - Fax:202-854-4854
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-18
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHFD01-0212133V00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD463400400Medicaid