MEDICARE: C. EDWARD SKEETERS,M.D. & MICHAEL P. GARDNER,M.D.

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	174400000X	Specialist	MD07790	OR

General Provider Information

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

Provider Business Mailing Address
First Line	:	19250 SW 65TH AVE STE 235
Second Line	:
City	:	TUALATIN
State	:	OR
Zip	:	97062-7745
Country	:	US
Telephone Number	:	503-692-1470
Fax Number	:	503-691-0234

Provider Business Practice Location Address
First Line	:	19250 SW 65TH AVE STE 235
Second Line	:
City	:	TUALATIN
State	:	OR
Zip	:	97062-7745
Country	:	US
Telephone Number	:	503-692-1470
Fax Number	:	503-691-0234

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MELANIE A ROBERTS IV
Credential	:
Telephone Number	:	503-692-1470

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	08/22/2020

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