Provider Demographics
NPI:1902892391
Name:PEACEHEALTH
Entity Type:Organization
Organization Name:PEACEHEALTH
Other - Org Name:COTTAGE GROVE COMMUNITY MEDICAL CT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-686-7034
Mailing Address - Street 1:PO BOX 569
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-0569
Mailing Address - Country:US
Mailing Address - Phone:541-686-7191
Mailing Address - Fax:
Practice Address - Street 1:1515 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-9700
Practice Address - Country:US
Practice Address - Phone:541-686-7191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR400223282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR237519Medicaid
OR237519Medicaid
ORCB3872Medicare PIN
OR381301Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
ORR105712Medicare PIN