1902892391 NPI number — PEACEHEALTH

Table of content: (NPI 1902892391)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902892391 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:
COTTAGE GROVE COMMUNITY MEDICAL CT
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:
1902892391
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 569
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUGENE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97440-0569
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-686-7191
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1515 VILLAGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COTTAGE GROVE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97424-9700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-686-7191
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
LIZ
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
541-686-7034

Provider Taxonomy Codes

  • Taxonomy code: 282NC0060X , with the licence number:  400223 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 237519 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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