Basic Information
| Provider Information | |||||||||
| NPI: | 1780631267 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEACEHEALTH MEDICAL GROUP COTTAGE GROVE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24410 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974020451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607291566 | ||||||||
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| Practice Location | |||||||||
| Address1: | 98 W OREGON AVE | ||||||||
| Address2: | |||||||||
| City: | CRESWELL | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974269259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412227700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 06/04/2013 | ||||||||
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| AuthorizedOfficialLastName: | APLAND | ||||||||
| AuthorizedOfficialFirstName: | WENDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5416863968 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 130008 | 05 | OR | MEDICAID |