Provider Demographics
NPI:1447428925
Name:CHERYL B. HICKETHIER, PC
Entity Type:Organization
Organization Name:CHERYL B. HICKETHIER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKETHIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:503-656-5657
Mailing Address - Street 1:14831 SE 82ND DR
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-7624
Mailing Address - Country:US
Mailing Address - Phone:503-656-5657
Mailing Address - Fax:503-656-5658
Practice Address - Street 1:14831 SE 82ND DR
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-7624
Practice Address - Country:US
Practice Address - Phone:503-656-5657
Practice Address - Fax:503-656-5658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-18
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15365207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR112528Medicare PIN