Provider Demographics
NPI:1568899698
Name:PEACEHEALTH UNITED GENERAL MEDICAL CENTER
Entity Type:Organization
Organization Name:PEACEHEALTH UNITED GENERAL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENROLLMENT LEAD
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:KETTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-729-1411
Mailing Address - Street 1:PO BOX 748636
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-8636
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SEDRO WOOLLEY
Practice Address - State:WA
Practice Address - Zip Code:98284-4327
Practice Address - Country:US
Practice Address - Phone:360-856-6021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-03
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHAC.FS.60417818275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2005537Medicaid
WA50Z329Medicare Oscar/Certification