Provider Demographics
NPI:1487922803
Name:PHS GLENN DALE
Entity type:Organization
Organization Name:PHS GLENN DALE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/COO
Authorized Official - Prefix:
Authorized Official - First Name:BEAU
Authorized Official - Middle Name:
Authorized Official - Last Name:HIGGINBOTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-368-3162
Mailing Address - Street 1:1160 VARNUM ST NE
Mailing Address - Street 2:ST CATHERINE'S HALL, ROOM 102
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2107
Mailing Address - Country:US
Mailing Address - Phone:202-854-4069
Mailing Address - Fax:202-854-7825
Practice Address - Street 1:12200 ANNAPOLIS RD
Practice Address - Street 2:SUITE 123
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-9182
Practice Address - Country:US
Practice Address - Phone:202-448-4014
Practice Address - Fax:202-372-0029
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-13
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHFD01-0212282N00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No282N00000XHospitalsGeneral Acute Care HospitalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA09810714Medicaid
MD005145400Medicaid
DC029833400Medicaid
090006Medicare PIN