Basic Information
| Provider Information | |||||||||
| NPI: | 1073510277 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEACEHEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. JOHN MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3002 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986320302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604142000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1615 DELAWARE ST | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986322310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604142000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2005 | ||||||||
| LastUpdateDate: | 01/26/2016 | ||||||||
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| AuthorizedOfficialLastName: | RABOIN | ||||||||
| AuthorizedOfficialFirstName: | KIRK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CAO | ||||||||
| AuthorizedOfficialTelephone: | 3604142000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 276400000X | H-026 | WA | N | Hospital Units | Rehabilitation, Substance Use Disorder Unit | 282N00000X | H-026 | WA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 600 521 489 | 01 | UBI NUMBER | OTHER | 3304508 | 05 | WA | MEDICAID |