Provider Demographics
NPI:1669453809
Name:PROVIDENCE HEALTH SERVICES INC
Entity type:Organization
Organization Name:PROVIDENCE HEALTH SERVICES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:LOMAX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:667-234-2926
Mailing Address - Street 1:1150 VARNUM ST NE
Mailing Address - Street 2:ADMINISTRATION 4TH FLOOR
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2149
Mailing Address - Country:US
Mailing Address - Phone:202-854-4255
Mailing Address - Fax:202-854-7160
Practice Address - Street 1:1160 VARNUM ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2107
Practice Address - Country:US
Practice Address - Phone:202-854-7000
Practice Address - Fax:202-269-7160
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-06
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 208600000X, 208M00000X, 103TH0100X, 363L00000X, 207Q00000X, 208M00000X
DCHFD01-0212251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC023435102Medicaid
DC023435100Medicaid
DC080352200Medicaid
DC5485215 00Medicaid
MD023435101Medicaid
MD5485215 01Medicaid
DC602021Medicare PIN
DC196441Medicare PIN
DC179071Medicare PIN
DC023435100Medicaid
DC5485215 00Medicaid
DC538834Medicare PIN