MEDICARE: MERIDIAN CENTER FOR SURGICAL EXCELLENCE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1366638843
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERIDIAN CENTER FOR SURGICAL EXCELLENCE

Provider Business Mailing Address
First Line	:	19801 SW 72ND AVE
Second Line	:	SUITE 170
City	:	TUALATIN
State	:	OR
Zip	:	97062-8351
Country	:	US
Telephone Number	:	503-783-0542
Fax Number	:	503-783-0545

Provider Business Practice Location Address
First Line	:	19801 SW 72ND AVE
Second Line	:	SUITE 170
City	:	TUALATIN
State	:	OR
Zip	:	97062-8351
Country	:	US
Telephone Number	:	503-783-0542
Fax Number	:	503-783-0545

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. TIMOTHY PATRICK CONNALL
Credential	:	MD
Telephone Number	:	503-783-0542

Provider Enumeration Date	:	09/19/2007
Last Update Date	:	09/19/2007

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