Basic Information
| Provider Information | |||||||||
| NPI: | 1508958331 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEACEHEALTH | ||||||||
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| OtherOrganizationName: | ST. JOHN MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 SE 164TH AVE | ||||||||
| Address2: | DEPT 364 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986839324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604142000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986323256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604142000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 07/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | HAYWOOD | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | NETWORK CFO | ||||||||
| AuthorizedOfficialTelephone: | 3604142173 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | H-026 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 3304508 | 05 | WA | MEDICAID | 600521489 | 01 | WA | UBI | OTHER | H-026 | 01 | WA | DOH LICENSE # | OTHER |