Provider Demographics
NPI:1922398734
Name:WISCONSIN AVENUE PSYCHIATRIC CENTER
Entity Type:Organization
Organization Name:WISCONSIN AVENUE PSYCHIATRIC CENTER
Other - Org Name:PSYCHIATRIC INSTITUTE OF WASHINGTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF CORPORATE OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:BAUMGARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-885-5600
Mailing Address - Street 1:4228 WISCONSIN AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20016-2138
Mailing Address - Country:US
Mailing Address - Phone:202-885-5600
Mailing Address - Fax:202-966-7374
Practice Address - Street 1:4228 WISCONSIN AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20016-2138
Practice Address - Country:US
Practice Address - Phone:202-885-5600
Practice Address - Fax:202-966-7374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-13
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD074500601Medicaid
DC026402100Medicaid
MD074500601Medicaid