Basic Information
| Provider Information | |||||||||
| NPI: | 1134658479 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEACEHEALTH MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PHMG URGENT CARE VALLEY RIVER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 SE 164TH AVE DEPT 358 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986838004 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1400 VALLEY RIVER DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974016758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412227378 | ||||||||
| FaxNumber: | 5412227389 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2017 | ||||||||
| LastUpdateDate: | 06/09/2017 | ||||||||
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| AuthorizedOfficialLastName: | METCALF | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE PHMG | ||||||||
| AuthorizedOfficialTelephone: | 3607291743 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.