Basic Information
| Provider Information | |||||||||
| NPI: | 1902232507 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEACEHEALTH PEACE ISLAND MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | PEACE ISLAND MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 SE 164TH AVE DEPT 358 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986838004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607292161 | ||||||||
| FaxNumber: | 5414318213 | ||||||||
| Practice Location | |||||||||
| Address1: | 1117 SPRING ST | ||||||||
| Address2: | |||||||||
| City: | FRIDAY HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982509782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603782141 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2013 | ||||||||
| LastUpdateDate: | 08/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | SAXTON | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP & GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 3607291108 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 08/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | HAC.FS.60316803 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207Q00000X | HAC.FS.60316803 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.