MEDICARE: PEACEHEALTH MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1356806202
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACEHEALTH MEDICAL GROUP

Provider Business Mailing Address
First Line	:	1115 SE 164TH AVE DEPT 358
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98683-8004
Country	:	US
Telephone Number	:	360-729-1462
Fax Number	:	360-729-3104

Provider Business Practice Location Address
First Line	:	2846 WILLAMETTE ST
Second Line	:
City	:	EUGENE
State	:	OR
Zip	:	97405-8200
Country	:	US
Telephone Number	:	541-222-6565
Fax Number	:	541-222-6567

Authorized Official
Title or Position	:	CHIEF EXECUTIVE PHMG
Name	:	MICHAEL CHARLES METCALF
Credential	:
Telephone Number	:	360-729-1743

Provider Enumeration Date	:	02/05/2019
Last Update Date	:	02/05/2019

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