Provider Demographics
NPI:1194733360
Name:MARY'S PEAK EMERGENCY PHYSICIANS
Entity type:Organization
Organization Name:MARY'S PEAK EMERGENCY PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:D
Authorized Official - Last Name:GOWING
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:541-768-5021
Mailing Address - Street 1:PO BOX 96353
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73143-6353
Mailing Address - Country:US
Mailing Address - Phone:800-962-3303
Mailing Address - Fax:
Practice Address - Street 1:3600 NW SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3737
Practice Address - Country:US
Practice Address - Phone:541-768-5021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR078548Medicaid
ORR0000WFBMRMedicare PIN