Healthcare Provider Details

I. General information

NPI: 1902968373
Provider Name (Legal Business Name): C. EDWARD SKEETERS,M.D. & MICHAEL P. GARDNER,M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19250 SW 65TH AVE STE 235
TUALATIN OR
97062-7745
US

IV. Provider business mailing address

19250 SW 65TH AVE STE 235
TUALATIN OR
97062-7745
US

V. Phone/Fax

Practice location:
  • Phone: 503-692-1470
  • Fax: 503-691-0234
Mailing address:
  • Phone: 503-692-1470
  • Fax: 503-691-0234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD07790
License Number StateOR

VIII. Authorized Official

Name: MELANIE A ROBERTS IV
Title or Position: OFFICE MANAGER
Credential:
Phone: 503-692-1470