Provider Demographics
NPI:1083672273
Name:PEACEHEALTH
Entity Type:Organization
Organization Name:PEACEHEALTH
Other - Org Name:ST JOSEPH MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE PHMG
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:METCALF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-729-1743
Mailing Address - Street 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:360-729-1462
Mailing Address - Fax:360-729-3104
Practice Address - Street 1:809 E CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-5221
Practice Address - Country:US
Practice Address - Phone:360-715-6427
Practice Address - Fax:360-715-6431
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST JOSEPH HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-04
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA50T030OtherMEDICARE PTAN
WA2006940Medicaid