1922018639 NPI number — PEACEHEALTH MEDICAL GROUP

Table of content: (NPI 1922018639)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922018639 NPI number — PEACEHEALTH MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEACEHEALTH MEDICAL GROUP
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 RIVERBEND OUTPATIENT PHARMACY
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:
1922018639
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3333 RIVERBEND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97477-8800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-222-5800
Provider Business Mailing Address Fax Number:
541-431-9149

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3333 RIVERBEND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97477-8800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-222-5800
Provider Business Practice Location Address Fax Number:
541-431-9149
Provider Enumeration Date:
08/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLACK
Authorized Official First Name:
BRENNAN
Authorized Official Middle Name:
DUANE
Authorized Official Title or Position:
PHARMACY MANAGER/PIC
Authorized Official Telephone Number:
541-222-5800

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  RP-0000785-CS , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHAO1124 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336S0011X , with the licence number: PHNR.FO.60259219 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 053967 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2077299 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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