Provider Demographics
NPI:1902232507
Name:PEACEHEALTH PEACE ISLAND MEDICAL CENTER
Entity Type:Organization
Organization Name:PEACEHEALTH PEACE ISLAND MEDICAL CENTER
Other - Org Name:PEACE ISLAND MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP & GENERAL COUNSEL
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SAXTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-729-1108
Mailing Address - Street 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:360-729-2161
Mailing Address - Fax:541-431-8213
Practice Address - Street 1:1117 SPRING ST
Practice Address - Street 2:
Practice Address - City:FRIDAY HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98250-9782
Practice Address - Country:US
Practice Address - Phone:360-378-2141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-16
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHAC.FS.60316803207Q00000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA501340Medicare UPIN