MEDICARE: DR. MARCUS H CORNWALL D.O.

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	207Q00000X	Family Medicine Physician	DO23052	OR

General Provider Information

NPI Number	:	1689639841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARCUS H CORNWALL D.O.

Provider Business Mailing Address
First Line	:	6975 SE LAKE RD
Second Line	:
City	:	MILWAUKIE
State	:	OR
Zip	:	97267-2103
Country	:	US
Telephone Number	:	503-905-2526
Fax Number	:	503-905-2545

Provider Business Practice Location Address
First Line	:	6975 SE LAKE RD
Second Line	:
City	:	MILWAUKIE
State	:	OR
Zip	:	97267-2103
Country	:	US
Telephone Number	:	503-905-2526
Fax Number	:	503-905-2545

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2006
Last Update Date	:	07/08/2007

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