MEDICARE: MERIDIAN PARK ONCOLOGY LLC

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	2085R0001X	Radiation Oncology Physician

General Provider Information

NPI Number	:	1467996645
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERIDIAN PARK ONCOLOGY LLC

Provider Business Mailing Address
First Line	:	6489 SW BORLAND RD
Second Line	:
City	:	TUALATIN
State	:	OR
Zip	:	97062-9798
Country	:	US
Telephone Number	:	503-692-4843
Fax Number	:

Provider Business Practice Location Address
First Line	:	6489 SW BORLAND RD
Second Line	:
City	:	TUALATIN
State	:	OR
Zip	:	97062-9798
Country	:	US
Telephone Number	:	503-692-4843
Fax Number	:

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MS. MELODY EDGINGTON
Credential	:
Telephone Number	:	503-692-4843

Provider Enumeration Date	:	12/07/2016
Last Update Date	:	12/07/2016

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