Provider Demographics
NPI:1316160237
Name:COLUMBIA RHEUMATOLOGY
Entity type:Organization
Organization Name:COLUMBIA RHEUMATOLOGY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:J
Authorized Official - Last Name:PEACOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-783-2000
Mailing Address - Street 1:512 N YOUNG ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7806
Mailing Address - Country:US
Mailing Address - Phone:509-783-2000
Mailing Address - Fax:509-783-2008
Practice Address - Street 1:512 N YOUNG ST
Practice Address - Street 2:SUITE C
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7806
Practice Address - Country:US
Practice Address - Phone:509-783-2000
Practice Address - Fax:509-783-2008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036578207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1104777Medicaid
WAG18710Medicare UPIN
WAAB34495Medicare ID - Type UnspecifiedGROUP NUMBER
WAAB34496Medicare ID - Type UnspecifiedPROVIDER NUMBER