Organization
PHS PROVIDENCE DIABETES AND NUTRITION CENTER
Active
Parent organization
PROVIDENCE HOSPITAL
Other names
PHS Joslin Diabetes Center DP110
Organization subpart
Yes
Provider details
NPI number
Legal business name
PROVIDENCE HOSPITAL
Authorized official
BEAU HIGGINBOTHAM (VICE PRESIDENT/COO)
(410) 368-3162
Entity
Organization
Contact information
Practice address
1160 VARNUM ST NE, DEPAUL 110, WASHINGTON, DC 20017-2107
(202) 854-7123
(202) 854-4854
Mailing address
1160 VARNUM ST NE, ST. CATHERINE'S HALL, ROOM 102, WASHINGTON, DC 20017-2107
(202) 854-4069
(202) 854-7825
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
HFD01-0212
DC
208600000X
Surgery Physician
HFD01-0212
DC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
463400400
—
MD
Enumeration date
07/18/2008
Last updated
10/09/2017
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