Organization
PHS FAMILY MEDICINE GLENN DALE
Active
Parent organization
PROVIDENCE HOSPITAL
Other names
Providence Health Services, Inc
Organization subpart
Yes
Provider details
NPI number
Legal business name
PROVIDENCE HOSPITAL
Authorized official
MR. CHARLES F HABERKERN (VP)
(202) 854-4255
Entity
Organization
Contact information
Practice address
12200 ANNAPOLIS RD, SUITE 118, GLENN DALE, MD 20769-9182
(301) 464-9300
(202) 854-4093
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
207Q00000X
Family Medicine 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
06/28/2013
Last updated
09/06/2016
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