Provider Demographics
NPI:1609142595
Name:PEACEHEALTH
Entity Type:Organization
Organization Name:PEACEHEALTH
Other - Org Name:COTTAGE GROVE COMMUNITY MEDICAL CT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:APLAND
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:541-686-3858
Mailing Address - Street 1:1515 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-9700
Mailing Address - Country:US
Mailing Address - Phone:541-686-7034
Mailing Address - Fax:541-335-2325
Practice Address - Street 1:1515 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-9700
Practice Address - Country:US
Practice Address - Phone:541-686-7034
Practice Address - Fax:541-335-2325
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEACEHEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-26
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR40 0223275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR38Z301Medicare Oscar/Certification