Provider Demographics
NPI:1073510277
Name:PEACEHEALTH
Entity Type:Organization
Organization Name:PEACEHEALTH
Other - Org Name:ST. JOHN MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SYS VP FIN INTEGRITY/CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SEIRER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-729-1132
Mailing Address - Street 1:1115 SE 164TH AVE DEPT 328
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8003
Mailing Address - Country:US
Mailing Address - Phone:360-729-1462
Mailing Address - Fax:360-729-3104
Practice Address - Street 1:1615 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2310
Practice Address - Country:US
Practice Address - Phone:360-414-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-01
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAH-026276400000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
600 521 489OtherUBI NUMBER
WA3304508Medicaid
WAAB19449Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
WA3304508Medicaid