Provider Demographics
NPI:1902968373
Name:C. EDWARD SKEETERS,M.D. & MICHAEL P. GARDNER,M.D.
Entity Type:Organization
Organization Name:C. EDWARD SKEETERS,M.D. & MICHAEL P. GARDNER,M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:IV
Authorized Official - Credentials:
Authorized Official - Phone:503-692-1470
Mailing Address - Street 1:19250 SW 65TH AVE STE 235
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-7745
Mailing Address - Country:US
Mailing Address - Phone:503-692-1470
Mailing Address - Fax:503-691-0234
Practice Address - Street 1:19250 SW 65TH AVE STE 235
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7745
Practice Address - Country:US
Practice Address - Phone:503-692-1470
Practice Address - Fax:503-691-0234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD07790174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty