Provider Demographics
NPI:1083054373
Name:PETER E. PALACIO, M.D., PC
Entity Type:Organization
Organization Name:PETER E. PALACIO, M.D., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:E
Authorized Official - Last Name:PALACIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-323-3747
Mailing Address - Street 1:2450 NE MARY ROSE PL
Mailing Address - Street 2:SUITE 220
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7132
Mailing Address - Country:US
Mailing Address - Phone:541-323-3747
Mailing Address - Fax:
Practice Address - Street 1:2450 NE MARY ROSE PL
Practice Address - Street 2:SUITE 220
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7132
Practice Address - Country:US
Practice Address - Phone:541-323-3747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-01
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23150207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287546Medicaid
ORR112543Medicare PIN