Provider Demographics
| NPI: | 1356309553 |
|---|---|
| Name: | PEACEHEALTH |
| Entity Type: | Organization |
| Organization Name: | PEACEHEALTH |
| Other - Org Name: | PEACEHEALTH MEDICAL GROUP |
| Other - Org Type: | Doing Business As |
| Authorized Official - Title/Position: | EVP CHIEF FINANCIAL /GROWTH OFFICER |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | DARRIN |
| Authorized Official - Middle Name: | MITCHELL |
| Authorized Official - Last Name: | MONTALVO |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 360-729-1102 |
| 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: | 360-729-2150 |
| Mailing Address - Fax: | 541-431-8213 |
| Practice Address - Street 1: | 2901 SQUALICUM PKWY |
| Practice Address - Street 2: | |
| Practice Address - City: | BELLINGHAM |
| Practice Address - State: | WA |
| Practice Address - Zip Code: | 98225-1851 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 360-734-5400 |
| Practice Address - Fax: | 360-756-6830 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-05-04 |
| Last Update Date: | 2020-11-30 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207K00000X | Allopathic & Osteopathic Physicians | Allergy & Immunology | Group - Multi-Specialty | |
| No | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology | Group - Multi-Specialty | |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
| No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
| No | 2086S0129X | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | Group - Multi-Specialty |
| No | 208C00000X | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | Group - Multi-Specialty | |
| No | 208G00000X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | Group - Multi-Specialty | |
| No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty | |
| No | 261QS1200X | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| WA | 7010440 | Medicaid | |
| WA | 7098361 | Medicaid | |
| WA | G001480200 | Medicare PIN | |
| WA | 7098361 | Medicaid | |
| WA | G001449200 | Medicare PIN | |
| WA | G001480300 | Medicare PIN | |
| WA | GAB11335 | Medicare PIN | |
| WA | G001480100 | Medicare PIN |
