Basic Information
| Provider Information | |||||||||
| NPI: | 1083672273 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEACEHEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST JOSEPH 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: | 3607291462 | ||||||||
| FaxNumber: | 3607293104 | ||||||||
| Practice Location | |||||||||
| Address1: | 809 E CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982255221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607156427 | ||||||||
| FaxNumber: | 3607156431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 09/19/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | METCALF | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | CHARLES | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE PHMG | ||||||||
| AuthorizedOfficialTelephone: | 3607291743 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST JOSEPH HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 50T030 | 01 | WA | MEDICARE PTAN | OTHER | 2006940 | 05 | WA | MEDICAID |