Provider Demographics
NPI:1255501698
Name:KENNETH P MELVIN, MD, PC
Entity Type:Organization
Organization Name:KENNETH P MELVIN, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:MELVIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-203-1177
Mailing Address - Street 1:4035 MERCANTILE DR
Mailing Address - Street 2:SUITE 112
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-2546
Mailing Address - Country:US
Mailing Address - Phone:503-203-1177
Mailing Address - Fax:503-203-1178
Practice Address - Street 1:4035 MERCANTILE DR
Practice Address - Street 2:SUITE 112
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2546
Practice Address - Country:US
Practice Address - Phone:503-203-1177
Practice Address - Fax:503-203-1178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-29
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24232261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD24232OtherOREGON LICENSE