Provider Demographics
NPI:1609031632
Name:PROVIDENCE HEALTH SERVICES, INC
Entity type:Organization
Organization Name:PROVIDENCE HEALTH SERVICES, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/CFO
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:LOMAX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:667-234-2926
Mailing Address - Street 1:1150 VARNUM ST NE
Mailing Address - Street 2:ST CATHERINES HALL 102
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2180
Mailing Address - Country:US
Mailing Address - Phone:202-854-4069
Mailing Address - Fax:202-269-7825
Practice Address - Street 1:1140 VARNUM ST NE STE 100
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017
Practice Address - Country:US
Practice Address - Phone:202-854-7623
Practice Address - Fax:202-854-7616
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-18
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHFD01-0212101Y00000X, 103T00000X, 104100000X, 2084A0401X, 2084B0040X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
No2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & NeuropsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD985415100Medicaid