Provider Demographics
NPI:1740795293
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/COO
Authorized Official - Prefix:
Authorized Official - First Name:BEAU
Authorized Official - Middle Name:
Authorized Official - Last Name:HIGGINBOTHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-368-3182
Mailing Address - Street 1:1150 VARNUM ST NE
Mailing Address - Street 2:ST CATHERINES HALL, ROOM 102
Mailing Address - City:20017
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2104
Mailing Address - Country:US
Mailing Address - Phone:202-854-4069
Mailing Address - Fax:202-854-7825
Practice Address - Street 1:1150 VARNUM ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2104
Practice Address - Country:US
Practice Address - Phone:202-854-4041
Practice Address - Fax:202-854-4034
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHFD01-0212207L00000X, 367500000X, 367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist AssistantGroup - Multi-Specialty