Provider Demographics
NPI:1235307331
Name:JIMMY HUEBERT MD INC
Entity Type:Organization
Organization Name:JIMMY HUEBERT MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUEBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-885-8008
Mailing Address - Street 1:6464 SW BORLAND RD STE D2
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-8861
Mailing Address - Country:US
Mailing Address - Phone:503-885-8008
Mailing Address - Fax:503-885-8002
Practice Address - Street 1:6464 SW BORLAND RD STE D2
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8861
Practice Address - Country:US
Practice Address - Phone:503-885-8008
Practice Address - Fax:503-885-8002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23362207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR131294OtherINDIVIDUAL MEDICARE PIN#
OR131294OtherINDIVIDUAL MEDICARE PIN#
OR131293Medicare PIN