NPIMap

Organization Active NPI

Providence Health Services, Inc

Doing business as PHS Otolaryngology PMB200

  • Otolaryngology Physician
  • Washington, DC
National Provider Identifier
1366710766
Registry record updated Feb 1, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Otolaryngology PhysicianTaxonomy code 207Y00000X
License
HFD01-0212 Issued in DC
Legal business name
PROVIDENCE HEALTH SERVICES, INC
Doing business as
PHS Otolaryngology PMB200
Practice address
1140 Varnum St NE
PMB 200
Washington, DC 20017-2151
Phone
(202) 854-4355
Fax
(202) 854-4398
NPI assigned
Dec 13, 2011
Last updated
Feb 1, 2018By the provider in NPPES
Organization subpart
Yes
Parent organization
PROVIDENCE HOSPITALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 1, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Beau Higginbothan
Title
Vice President/Coo
Phone
(410) 368-3182

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Otolaryngology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Y00000X HFD01-0212 DC Primary
General Acute Care Hospital 282N00000X HFD01-0212 DC

Addresses

Primary practice location

1140 Varnum St NE
PMB 200
Washington, DC 20017-2151

Mailing address

1160 Varnum St NE
St Catherine's Hall, Room 102
Washington, DC 20017-2107
Phone (202) 854-4069

Other identifiers 1

IdentifierTypeStateIssuer
548521500MedicaidMD

Other names 1

  • PHS Otolaryngology PMB200 Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Providence Health Service-18 organizations share this tax ID, including this one
Part of
PHS General Surgry Dp318

Other organizations with this tax ID 17

Organizations that report the same tax identification number in the National Provider Directory.

View all 17

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1323734400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1517443200000",
    "number": "1366710766",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1160 VARNUM ST NE",
            "address_2": "ST CATHERINE'S HALL, ROOM 102",
            "city": "WASHINGTON",
            "state": "DC",
            "postal_code": "200172107",
            "telephone_number": "202-854-4069",
            "fax_number": "202-854-7825"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1140 VARNUM ST NE",
            "address_2": "PMB 200",
            "city": "WASHINGTON",
            "state": "DC",
            "postal_code": "200172151",
            "telephone_number": "202-854-4355",
            "fax_number": "202-854-4398"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH SERVICES, INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PROVIDENCE HOSPITAL",
        "enumeration_date": "2011-12-13",
        "last_updated": "2018-02-01",
        "status": "A",
        "authorized_official_last_name": "HIGGINBOTHAN",
        "authorized_official_first_name": "BEAU",
        "authorized_official_title_or_position": "VICE PRESIDENT/COO",
        "authorized_official_telephone_number": "410-368-3182"
    },
    "taxonomies": [
        {
            "code": "207Y00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Otolaryngology",
            "state": "DC",
            "license": "HFD01-0212",
            "primary": true
        },
        {
            "code": "282N00000X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital",
            "state": "DC",
            "license": "HFD01-0212",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "548521500",
            "state": "MD"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PHS Otolaryngology PMB200",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Washington, DC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 1, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.