1780631267 NPI number — PEACEHEALTH MEDICAL GROUP COTTAGE GROVE

Table of content: (NPI 1780631267)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780631267 NPI number — PEACEHEALTH MEDICAL GROUP COTTAGE GROVE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEACEHEALTH MEDICAL GROUP COTTAGE GROVE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780631267
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 24410
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUGENE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97402-0451
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-729-1566
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
98 W OREGON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRESWELL
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97426-9259
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-222-7700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
APLAND
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
541-686-3968

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 130008 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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