Provider Demographics
NPI:1972615656
Name:PROVIDENCE CARDIOLOGY ASSOCIATES, PC
Entity type:Organization
Organization Name:PROVIDENCE CARDIOLOGY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LOIS
Authorized Official - Middle Name:I
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-220-0150
Mailing Address - Street 1:4700 BERWYN HOUSE RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740
Mailing Address - Country:US
Mailing Address - Phone:301-220-0150
Mailing Address - Fax:301-220-1032
Practice Address - Street 1:1150 VARNUM ST NE
Practice Address - Street 2:PROVIDENCE HOSPITAL
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017
Practice Address - Country:US
Practice Address - Phone:202-269-7118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC024607200Medicaid
DC024607200Medicaid
DC132472Medicare PIN