Provider Demographics
NPI:1407283179
Name:PEACEHEALTH MEDICAL GROUP - SEDRO WOOLLEY
Entity Type:Organization
Organization Name:PEACEHEALTH MEDICAL GROUP - SEDRO WOOLLEY
Other - Org Name:PEACEHEALTH MEDICAL GROUP - SEDRO WOOLLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HODGKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-729-1145
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:360-729-1411
Mailing Address - Fax:360-501-7535
Practice Address - Street 1:1990 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SEDRO WOOLLEY
Practice Address - State:WA
Practice Address - Zip Code:98284
Practice Address - Country:US
Practice Address - Phone:360-856-8810
Practice Address - Fax:360-714-2520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-26
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2036892Medicaid