Provider Demographics
NPI:1871810945
Name:PEACEHEALTH
Entity type:Organization
Organization Name:PEACEHEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NETWORK CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-414-2000
Mailing Address - Street 1:1115 SE 164TH AVE
Mailing Address - Street 2:DEPT. 364
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9324
Mailing Address - Country:US
Mailing Address - Phone:360-414-2000
Mailing Address - Fax:
Practice Address - Street 1:812 OCEAN BEACH HWY
Practice Address - Street 2:STE. 200
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-4082
Practice Address - Country:US
Practice Address - Phone:360-636-6900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-28
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0466190006Medicare NSC