Basic Information
| Provider Information | |||||||||
| NPI: | 1487917233 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEACEHEALTH PEACE ISLAND MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PEACE ISLAND MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1117 SPRING STREET | ||||||||
| Address2: | |||||||||
| City: | FRIDAY HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982507303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603782141 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1117 SPRING STREET | ||||||||
| Address2: | |||||||||
| City: | FRIDAY HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982507303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603782141 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2012 | ||||||||
| LastUpdateDate: | 01/08/2014 | ||||||||
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| AuthorizedOfficialLastName: | BARNHART | ||||||||
| AuthorizedOfficialFirstName: | JIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CAO | ||||||||
| AuthorizedOfficialTelephone: | 3603782141 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 2031204 | 05 | WA | MEDICAID |