Basic Information
| Provider Information | |||||||||
| NPI: | 1760704878 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEACEHEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PEACEHEALTH MEDICAL GROUP-DEXTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24410 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974020451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419844301 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 38843 DEXTER RD | ||||||||
| Address2: | |||||||||
| City: | DEXTER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974310110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419372134 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2010 | ||||||||
| LastUpdateDate: | 09/10/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | APLAND | ||||||||
| AuthorizedOfficialFirstName: | WENDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5416863968 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PEACEHEALTH | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 38 3808 | 01 | MEDICARE PART A PTAN | OTHER |