Organization
PHS GEN SURG DP307
Active
Parent organization
PROVIDENCE HOSPITAL
Other names
Providence Health Services
Organization subpart
Yes
Provider details
NPI number
Legal business name
PROVIDENCE HOSPITAL
Authorized official
BEAU HIGGINBOTHAM (CIVE PRESIDENT/COO)
(410) 368-3162
Entity
Organization
Contact information
Practice address
1160 VARNUM ST NE, DEPAUL 307, WASHINGTON, DC 20017-2107
(202) 854-4014
(202) 854-4082
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
208600000X
Surgery Physician
Primary
HFD01-0212
DC
282N00000X
General Acute Care Hospital
HFD01-0212
DC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
005145400
—
MD
05
—
029833400
—
DC
05
—
09810714
—
VA
Enumeration date
12/20/2012
Last updated
10/05/2017
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