=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306208897
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THOMAS P. MCWEENEY MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2016
-----------------------------------------------------
Last Update Date | 03/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19255 SW 65TH AVE SUITE 110
-----------------------------------------------------
City | TUALATIN
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97062-7451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-506-8384
-----------------------------------------------------
Fax | 503-506-8364
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19255 SW 65TH AVE SUITE 110
-----------------------------------------------------
City | TUALATIN
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97062-7451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-506-8384
-----------------------------------------------------
Fax | 503-506-8364
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. THOMAS MCWEENEY
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 503-506-8384
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MD16875
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------