NPIMap

Organization Active NPI

PHS Glenn Dale

  • Surgery Physician
  • Glenn Dale, MD
National Provider Identifier
1487922803
Registry record updated Oct 9, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Surgery PhysicianTaxonomy code 208600000X
License
HFD01-0212 Issued in DC
Legal business name
PHS GLENN DALE
Practice address
12200 Annapolis Rd
Suite 123
Glenn Dale, MD 20769-9182
Phone
(202) 448-4014
Fax
(202) 372-0029
NPI assigned
Dec 13, 2011
Organization subpart
Yes
Parent organization
PROVIDENCE HOSPITALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 9, 2017

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

Authorized official

Name
Beau Higginbotham
Title
Vice President/Coo
Phone
(410) 368-3162

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208600000X HFD01-0212 DC Primary
General Acute Care Hospital 282N00000X HFD01-0212 DC

Addresses

Primary practice location

12200 Annapolis Rd
Suite 123
Glenn Dale, MD 20769-9182

Mailing address

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

Other identifiers 3

IdentifierTypeStateIssuer
09810714MedicaidVA
005145400MedicaidMD
029833400MedicaidDC

Other names 1

  • Providence Health Services Other name

National Provider Directory

National Provider Directory
Tax ID family
Ft Lincoln Fam Medicine18 organizations share this tax ID, including this one
Part of
PHS Ctr for Geriatric Medicine Dp021

Other organizations with this tax ID 17

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

View all 17

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

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": "1507507200000",
    "number": "1487922803",
    "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": "12200 ANNAPOLIS RD",
            "address_2": "SUITE 123",
            "city": "GLENN DALE",
            "state": "MD",
            "postal_code": "207699182",
            "telephone_number": "202-448-4014",
            "fax_number": "202-372-0029"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PHS GLENN DALE",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PROVIDENCE HOSPITAL",
        "enumeration_date": "2011-12-13",
        "last_updated": "2017-10-09",
        "status": "A",
        "authorized_official_last_name": "HIGGINBOTHAM",
        "authorized_official_first_name": "BEAU",
        "authorized_official_title_or_position": "VICE PRESIDENT/COO",
        "authorized_official_telephone_number": "410-368-3162"
    },
    "taxonomies": [
        {
            "code": "208600000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Surgery",
            "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": "09810714",
            "state": "VA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "005145400",
            "state": "MD"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "029833400",
            "state": "DC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Providence Health Services",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Glenn Dale, MD

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 9, 2017; 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.