Basic Information
| Provider Information | |||||||||
| NPI: | 1255977591 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEACEHEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PEACEHEALTH LONGVIEW UROLOGY | ||||||||
| 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: | 625 9TH AVE STE 120 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986322465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606368950 | ||||||||
| FaxNumber: | 3606368951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2019 | ||||||||
| LastUpdateDate: | 11/27/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | METCALF | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | CHARLES | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE PHMG | ||||||||
| AuthorizedOfficialTelephone: | 3607291743 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PEACEHEALTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 208800000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.