Healthcare Provider Details

I. General information

NPI: 1255977591
Provider Name (Legal Business Name): PEACEHEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2019
Last Update Date: 11/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 9TH AVE STE 120
LONGVIEW WA
98632-2465
US

IV. Provider business mailing address

1115 SE 164TH AVE DEPT 358
VANCOUVER WA
98683-8004
US

V. Phone/Fax

Practice location:
  • Phone: 360-636-8950
  • Fax: 360-636-8951
Mailing address:
  • Phone: 360-729-1462
  • Fax: 360-729-3104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL CHARLES METCALF
Title or Position: CHIEF EXECUTIVE PHMG
Credential:
Phone: 360-729-1743