Provider Demographics
NPI:1780631267
Name:PEACEHEALTH MEDICAL GROUP COTTAGE GROVE
Entity Type:Organization
Organization Name:PEACEHEALTH MEDICAL GROUP COTTAGE GROVE
Other - Org Name:
Other - Org Type:
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:360-729-1566
Mailing Address - Fax:
Practice Address - Street 1:98 W OREGON AVE
Practice Address - Street 2:
Practice Address - City:CRESWELL
Practice Address - State:OR
Practice Address - Zip Code:97426-9259
Practice Address - Country:US
Practice Address - Phone:541-222-7700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR130008Medicaid
ORCI2646Medicare PIN
ORR102478Medicare PIN
OR1325410001Medicare NSC