NPIMap

Organization Active NPI

Peacehealth Medical Group - Sedro Woolley

  • Family Medicine Physician
  • Sedro Woolley, WA
National Provider Identifier
1407283179
Registry record updated Aug 21, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
PEACEHEALTH MEDICAL GROUP - SEDRO WOOLLEY
Doing business as
PeaceHealth Medical Group - Sedro Woolley
Practice address
1990 Hospital Dr
Sedro Woolley, WA 98284
Phone
(360) 856-8810
Fax
(360) 714-2520
NPI assigned
Sep 26, 2013
Last updated
Aug 21, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 21, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Kimberly A Hodgkinson
Title
Evp Cfo
Phone
(360) 729-1145

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X NU Primary

Addresses

Primary practice location

1990 Hospital Dr
Sedro Woolley, WA 98284

Mailing address

1115 SE 164TH Ave Dept 358
Vancouver, WA 98683-8004
Phone (360) 729-1411

Other identifiers 1

IdentifierTypeStateIssuer
2036892MedicaidWA

Other names 1

  • PeaceHealth Medical Group - Sedro Woolley Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20140506001293 WA Part B Supplier - Clinic/Group Practice 1456584036 Receives reassigned benefits from 126 practitioners
Practice locations: Burlington, WA; Sedro Woolley, WA

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
50D0634763Peacehealth Medical Group1990 Hospital Dr Ste 200, Sedro Woolley, WA 98284Provider-performed microscopyApr 4, 2028

National Provider Directory

National Provider Directory

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

  • Peacehealth

    dba PeaceHealth Home Health of Whatcom County

    • Home Health Agency
    • Bellingham, WA
    • NPI 1710639901

    Member Of

    NPD member

Locations

1990 Hospital Dr
Ste 110
Sedro Woolley, WA 98284
Phone (360) 856-8830

2061 Hospital Dr
Sedro Woolley, WA 98284
Phone (360) 856-7230

830 Ball St
Sedro Woolley, WA 98284
Phone (360) 855-1411

Practitioners & affiliated clinicians

Practitioners 130

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 130

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1380153600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1534809600000",
    "number": "1407283179",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1115 SE 164TH AVE DEPT 358",
            "city": "VANCOUVER",
            "state": "WA",
            "postal_code": "986838004",
            "telephone_number": "360-729-1411",
            "fax_number": "360-501-7535"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1990 HOSPITAL DR",
            "city": "SEDRO WOOLLEY",
            "state": "WA",
            "postal_code": "98284",
            "telephone_number": "360-856-8810",
            "fax_number": "360-714-2520"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEACEHEALTH MEDICAL GROUP - SEDRO WOOLLEY",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-09-26",
        "last_updated": "2018-08-21",
        "status": "A",
        "authorized_official_last_name": "HODGKINSON",
        "authorized_official_first_name": "KIMBERLY",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "EVP CFO",
        "authorized_official_telephone_number": "360-729-1145",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2036892",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PeaceHealth Medical Group - Sedro Woolley",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PeaceHealth Medical Group - Sedro Woolley",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Sedro Woolley, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 21, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.