Provider Demographics
NPI:1194985515
Name:PROVIDENCE HEALTH SERVICES
Entity type:Organization
Organization Name:PROVIDENCE HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT VP, PRACTICE MGT SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERIDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-269-7374
Mailing Address - Street 1:1150 VARNUM ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2149
Mailing Address - Country:US
Mailing Address - Phone:202-269-7286
Mailing Address - Fax:202-269-7825
Practice Address - Street 1:4151 BLADENSBURG RD
Practice Address - Street 2:
Practice Address - City:COLMAR MANOR
Practice Address - State:MD
Practice Address - Zip Code:20722-1928
Practice Address - Country:US
Practice Address - Phone:301-699-7700
Practice Address - Fax:301-779-9001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-10
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHFD01-0212207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD548521501Medicaid