NPIMap

Organization Active NPI

PHS Providence Diabetes and Nutrition Center

  • Registered Dietitian
  • Washington, DC
National Provider Identifier
1881859817
Registry record updated Oct 9, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Registered DietitianTaxonomy code 133V00000X
License
HFD01-0212 Issued in DC
Legal business name
PHS PROVIDENCE DIABETES AND NUTRITION CENTER
Practice address
1160 Varnum St NE
Depaul 110
Washington, DC 20017-2107
Phone
(202) 854-7123
Fax
(202) 854-4854
NPI assigned
Jul 18, 2008
Last updated
Oct 9, 2017By the provider in NPPES
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
Registered Dietitian 133V00000X HFD01-0212 DC Primary
Surgery Physician 208600000X HFD01-0212 DC

Addresses

Primary practice location

1160 Varnum St NE
Depaul 110
Washington, DC 20017-2107

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
463400400MedicaidMD

Other names 1

  • PHS Joslin Diabetes Center DP110 Other name

National Provider Directory

National Provider Directory
Tax ID family
PHS Emergency Room Serv18 organizations share this tax ID, including this one
Part of
Emerg Med Providence Ho

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": "1216339200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1507507200000",
    "number": "1881859817",
    "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": "1160 VARNUM ST NE",
            "address_2": "DEPAUL 110",
            "city": "WASHINGTON",
            "state": "DC",
            "postal_code": "200172107",
            "telephone_number": "202-854-7123",
            "fax_number": "202-854-4854"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PHS PROVIDENCE DIABETES AND NUTRITION CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PROVIDENCE HOSPITAL",
        "enumeration_date": "2008-07-18",
        "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": "133V00000X",
            "taxonomy_group": "",
            "desc": "Dietitian, Registered",
            "state": "DC",
            "license": "HFD01-0212",
            "primary": true
        },
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "DC",
            "license": "HFD01-0212",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "463400400",
            "state": "MD"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PHS Joslin Diabetes Center DP110",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

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 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.