| Providence Health Services, Inc | |
|
12200 Annapolis Rd Suite 118 Glenn Dale MD 20769-9182 | |
| (301) 464-9300 | |
| (202) 854-4093 |
| Full Name | Providence Health Services, Inc |
|---|---|
| Speciality | Family Medicine |
| Location | 12200 Annapolis Rd, Glenn Dale, Maryland |
| Authorized Official Name and Position | Charles F Haberkern (VP) |
| Authorized Official Contact | 2028544255 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Providence Health Services, Inc 1160 Varnum St Ne St Catherine's Hall, Room 102 Washington DC 20017-2107 Ph: (202) 854-4069 | Providence Health Services, Inc 12200 Annapolis Rd Suite 118 Glenn Dale MD 20769-9182 Ph: (301) 464-9300 |
| NPI Number | 1962842401 |
|---|---|
| Provider Enumeration Date | 06/28/2013 |
| Last Update Date | 09/06/2016 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1962842401 | NPI | - | NPPES |
| 029833400 | Medicaid | DC | |
| 09810714 | Medicaid | VA | |
| 005145400 | Medicaid | MD |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | HFD01-0212 (District Of Columbia) | Primary |
| 282N00000X | General Acute Care Hospital | HFD01-0212 (District Of Columbia) | Secondary |
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