Provider Demographics
NPI:1508958331
Name:PEACEHEALTH
Entity Type:Organization
Organization Name:PEACEHEALTH
Other - Org Name:ST. JOHN MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NETWORK CFO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-414-2173
Mailing Address - Street 1:1115 SE 164TH AVE
Mailing Address - Street 2:DEPT 364
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9324
Mailing Address - Country:US
Mailing Address - Phone:360-414-2000
Mailing Address - Fax:
Practice Address - Street 1:600 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3256
Practice Address - Country:US
Practice Address - Phone:360-414-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAH-026261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3304508Medicaid
WA600521489OtherUBI
WAH-026OtherDOH LICENSE #
WA600521489OtherUBI