1750659272 NPI number — PHS FAMILY MEDICINE & PEDIATRICS PMB103

Table of content: (NPI 1750659272)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750659272 NPI number — PHS FAMILY MEDICINE & PEDIATRICS PMB103

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHS FAMILY MEDICINE & PEDIATRICS PMB103
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750659272
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1160 VARNUM ST NE
Provider Second Line Business Mailing Address:
ST CATHERINE'S HALL, ROOM 102
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
DC
Provider Business Mailing Address Postal Code:
20017-2107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
202-854-4069
Provider Business Mailing Address Fax Number:
202-854-7825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1140 VARNUM ST NE
Provider Second Line Business Practice Location Address:
PMB103
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20017-2151
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-854-7074
Provider Business Practice Location Address Fax Number:
202-854-7470
Provider Enumeration Date:
12/12/2011

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  HFD01-0212 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: HFD01-0212 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282N00000X , with the licence number: HFD01-0212 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 005145100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 029833400 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09810714 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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