Healthcare Provider Details

I. General information

NPI: 1316160237
Provider Name (Legal Business Name): COLUMBIA RHEUMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 N YOUNG ST SUITE C
KENNEWICK WA
99336-7806
US

IV. Provider business mailing address

512 N YOUNG ST SUITE C
KENNEWICK WA
99336-7806
US

V. Phone/Fax

Practice location:
  • Phone: 509-783-2000
  • Fax: 509-783-2008
Mailing address:
  • Phone: 509-783-2000
  • Fax: 509-783-2008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD00036578
License Number StateWA

VIII. Authorized Official

Name: DEREK J PEACOCK
Title or Position: SOLE PROPRIETOR
Credential: MD
Phone: 509-783-2000