Provider Demographics
NPI:1609061969
Name:PEACEHEALTH
Entity Type:Organization
Organization Name:PEACEHEALTH
Other - Org Name:PEACEHEALTH MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP CHIEF FINAN-GROWTH OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DARRIN
Authorized Official - Middle Name:
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:DEPT 358
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9324
Mailing Address - Country:US
Mailing Address - Phone:360-729-1412
Mailing Address - Fax:360-501-7555
Practice Address - Street 1:505 NE 87TH AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-1965
Practice Address - Country:US
Practice Address - Phone:360-514-7374
Practice Address - Fax:360-514-7384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00027022208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7140890Medicaid
WA7140890Medicaid