1083672273 NPI number — PEACEHEALTH

Table of content: (NPI 1083672273)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083672273 NPI number — PEACEHEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEACEHEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ST JOSEPH MEDICAL CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083672273
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1115 SE 164TH AVE DEPT 358
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98683-8004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-729-1462
Provider Business Mailing Address Fax Number:
360-729-3104

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
809 E CHESTNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLINGHAM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98225-5221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-715-6427
Provider Business Practice Location Address Fax Number:
360-715-6431
Provider Enumeration Date:
05/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
METCALF
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
CHARLES
Authorized Official Title or Position:
CHIEF EXECUTIVE PHMG
Authorized Official Telephone Number:
360-729-1743

Provider Taxonomy Codes

  • Taxonomy code: 273Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 50T030 . This is a "MEDICARE PTAN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2006940 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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