Provider Demographics
NPI:1528544822
Name:PEACEHEALTH
Entity Type:Organization
Organization Name:PEACEHEALTH
Other - Org Name:KETCHIKAN MEDICAL CENTER
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
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9324
Mailing Address - Country:US
Mailing Address - Phone:360-729-1000
Mailing Address - Fax:
Practice Address - Street 1:3100 TONGASS AVE
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5746
Practice Address - Country:US
Practice Address - Phone:907-225-5171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-19
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit