=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497170849
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEGACY MERIDAN PARK HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2014
-----------------------------------------------------
Last Update Date | 03/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19300 SW 65TH AVE
-----------------------------------------------------
City | TUALATIN
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97062-7706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-692-7470
-----------------------------------------------------
Fax | 503-692-7437
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19300 SW 65TH AVE
-----------------------------------------------------
City | TUALATIN
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97062-7706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-692-2454
-----------------------------------------------------
Fax | 503-692-7437
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHCY SRVCS MGR
-----------------------------------------------------
Name | MICHAEL SIEG
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 503-692-2665
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | RP-0000864
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------