Provider Demographics
NPI:1962842401
Name:PHS FAMILY MEDICINE GLENN DALE
Entity Type:Organization
Organization Name:PHS FAMILY MEDICINE GLENN DALE
Other - Org Name:PROVIDENCE HEALTH SERVICES, INC
Other - Org Type:Other Name
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:F
Authorized Official - Last Name:HABERKERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-854-4255
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 1:12200 ANNAPOLIS RD
Practice Address - Street 2:SUITE 118
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-9182
Practice Address - Country:US
Practice Address - Phone:301-464-9300
Practice Address - Fax:202-854-4093
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-28
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHFD01-0212207Q00000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No282N00000XHospitalsGeneral Acute Care HospitalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC029833400Medicaid
VA09810714Medicaid
MD005145400Medicaid
MD005145400Medicaid