Basic Information
Provider Information | |||||||||
NPI: | 1609851492 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HIEBERT | ||||||||
FirstName: | TIMOTHY | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3590 | ||||||||
Address2: |   | ||||||||
City: | VICTORIA | ||||||||
State: | TX | ||||||||
PostalCode: | 779033590 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2284746111 | ||||||||
FaxNumber: | 3615764219 | ||||||||
Practice Location | |||||||||
Address1: | 3418 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | MOSS POINT | ||||||||
State: | MS | ||||||||
PostalCode: | 395635102 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2284746111 | ||||||||
FaxNumber: | 2254746113 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/14/2005 | ||||||||
LastUpdateDate: | 05/17/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | MD16489 | MS | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | 00121256 | 05 | MS |   | MEDICAID |