Provider Demographics
NPI:1457553497
Name:PEACEHEALTH
Entity type:Organization
Organization Name:PEACEHEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:J
Authorized Official - Last Name:ZENDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-788-6797
Mailing Address - Street 1:2901 SQUALICUM PARKWAY
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225
Mailing Address - Country:US
Mailing Address - Phone:360-734-5400
Mailing Address - Fax:360-756-3552
Practice Address - Street 1:2901 SQUALICUM PARKWAY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225
Practice Address - Country:US
Practice Address - Phone:360-734-5400
Practice Address - Fax:360-756-3552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 1041C0700X, 2084P0005X, 2084P0800X, 2080P0202X, 207RC0000X
WA261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0005XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurodevelopmental DisabilitiesGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1991272Medicaid
WA1992833Medicaid
WA7150014Medicaid
WA7010440Medicaid
WA7079056Medicaid
WA7150014Medicaid
WAG001480100Medicare PIN
WA7010440Medicaid