1255977591 NPI number — PEACEHEALTH

Table of content: (NPI 1255977591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255977591 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:
PEACEHEALTH LONGVIEW UROLOGY
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:
1255977591
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2019
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:
625 9TH AVE STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98632-2465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-636-8950
Provider Business Practice Location Address Fax Number:
360-636-8951
Provider Enumeration Date:
11/21/2019

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: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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