Provider Demographics
NPI:1235556846
Name:PEACEHEALTH
Entity Type:Organization
Organization Name:PEACEHEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-729-1411
Mailing Address - Street 1:1115 SE 164TH AVE
Mailing Address - Street 2:DEPT 358
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9324
Mailing Address - Country:US
Mailing Address - Phone:360-729-1411
Mailing Address - Fax:
Practice Address - Street 1:212 CARLANNA LAKE RD
Practice Address - Street 2:#204
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5642
Practice Address - Country:US
Practice Address - Phone:907-225-7346
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-20
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5790208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKK163430Medicare PIN