Provider Demographics
NPI:1821267907
Name:PEACEHEALTH
Entity Type:Organization
Organization Name:PEACEHEALTH
Other - Org Name:ST JOHN MEDICAL CENTER - INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL VP/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-414-5797
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-7154
Mailing Address - Country:US
Mailing Address - Phone:360-414-2092
Mailing Address - Fax:360-575-3367
Practice Address - Street 1:748 14TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2315
Practice Address - Country:US
Practice Address - Phone:360-501-3601
Practice Address - Fax:360-501-3648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0466190004Medicare NSC