Provider Demographics
NPI:1932190626
Name:PROVIDENCE HOSPITAL
Entity Type:Organization
Organization Name:PROVIDENCE HOSPITAL
Other - Org Name:PROVIDENCE HOSPITAL URGENT CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP FINANCE/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:M
Authorized Official - Last Name:FURNISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-854-7147
Mailing Address - Street 1:1150 VARNUM ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2104
Mailing Address - Country:US
Mailing Address - Phone:202-854-7000
Mailing Address - Fax:202-854-7160
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:202-854-7000
Practice Address - Fax:202-854-7160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QU0200X
DCHFD01-0212282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD005145400Medicaid
VA09810714Medicaid
DC029833400Medicaid
DC029833400Medicaid