Basic Information
| Provider Information | |||||||||
| NPI: | 1912960477 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HECOX | ||||||||
| FirstName: | KERRI | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1025 E MAIN ST STE 108 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975047448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412001530 | ||||||||
| FaxNumber: | 5417720284 | ||||||||
| Practice Location | |||||||||
| Address1: | 1025 E MAIN ST STE 108 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975047448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416181380 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 06/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD26021 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 022868 | 05 | OR | MEDICAID | 943096772 | 01 | FEDERAL TAX ID | OTHER |