Provider Demographics
NPI:1558475905
Name:PEACEHEALTH MEDICAL GROUP
Entity Type:Organization
Organization Name:PEACEHEALTH MEDICAL GROUP
Other - Org Name:SOUTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:APLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-686-3968
Mailing Address - Street 1:PO BOX 24410
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-0451
Mailing Address - Country:US
Mailing Address - Phone:541-349-7683
Mailing Address - Fax:
Practice Address - Street 1:3299 HILYARD ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97405-3721
Practice Address - Country:US
Practice Address - Phone:541-687-6016
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1042230005332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1042230005OtherDME LICENSE NUMBER
OR071634Medicaid
OR071634Medicaid