NPIMap

Organization Active NPI

PHS Family Medicine Glenn Dale

  • Family Medicine Physician
  • Glenn Dale, MD
National Provider Identifier
1962842401
Registry record updated Sep 6, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
HFD01-0212 Issued in DC
Legal business name
PHS FAMILY MEDICINE GLENN DALE
Practice address
12200 Annapolis Rd
Suite 118
Glenn Dale, MD 20769-9182
Phone
(301) 464-9300
Fax
(202) 854-4093
NPI assigned
Jun 28, 2013
Organization subpart
Yes
Parent organization
PROVIDENCE HOSPITALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 6, 2016

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

Authorized official

Name
Mr. Charles F Haberkern
Title
VP
Phone
(202) 854-4255

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X HFD01-0212 DC Primary
General Acute Care Hospital 282N00000X HFD01-0212 DC

Addresses

Primary practice location

12200 Annapolis Rd
Suite 118
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
029833400MedicaidDC
09810714MedicaidVA
005145400MedicaidMD

Other names 1

  • Providence Health Services, Inc Other name

National Provider Directory

National Provider Directory
Tax ID family
PHS Ctr for Geriatric Medicine Dp02123 organizations share this tax ID, including this one
Part of
PHS Ctr for Geriatric Medicine Dp021

Other organizations with this tax ID 22

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

View all 22

Locations

12200 Annapolis Rd
Ste 118
Glenn Dale, MD 20769
Phone (410) 897-6200

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.

NPI Registry JSON

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

{
    "created_epoch": "1372377600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1473120000000",
    "number": "1962842401",
    "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 118",
            "city": "GLENN DALE",
            "state": "MD",
            "postal_code": "207699182",
            "telephone_number": "301-464-9300",
            "fax_number": "202-854-4093"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PHS FAMILY MEDICINE GLENN DALE",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PROVIDENCE HOSPITAL",
        "enumeration_date": "2013-06-28",
        "last_updated": "2016-09-06",
        "status": "A",
        "authorized_official_last_name": "HABERKERN",
        "authorized_official_first_name": "CHARLES",
        "authorized_official_middle_name": "F",
        "authorized_official_title_or_position": "VP",
        "authorized_official_telephone_number": "202-854-4255",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "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": "029833400",
            "state": "DC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "09810714",
            "state": "VA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "005145400",
            "state": "MD"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Providence Health Services, Inc",
            "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 Sep 6, 2016; 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.