1154302925 NPI number — PEACEHEALTH

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154302925 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:
Provider Other Organization Name Type Code:
6
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:
1154302925
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2023
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 328
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:
98683-8003
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:
677 E 12TH AVE
Provider Second Line Business Practice Location Address:
SUITE N-170
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97401-3600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
458-205-7200
Provider Business Practice Location Address Fax Number:
458-205-7215
Provider Enumeration Date:
11/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SEIRER
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
SYS VP FIN INTEGRIT/CONTROLLER
Authorized Official Telephone Number:
360-729-1132

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 122767 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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