Basic Information
Provider Information | |||||||||
NPI: | 1689659377 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHERRY | ||||||||
FirstName: | UNKNOWN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1900 WOODLAND DR | ||||||||
Address2: |   | ||||||||
City: | COOS BAY | ||||||||
State: | OR | ||||||||
PostalCode: | 974200000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412675151 | ||||||||
FaxNumber: | 5412673800 | ||||||||
Practice Location | |||||||||
Address1: | 1900 WOODLAND DR | ||||||||
Address2: |   | ||||||||
City: | COOS BAY | ||||||||
State: | OR | ||||||||
PostalCode: | 974200000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412675151 | ||||||||
FaxNumber: | 5412673800 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/14/2005 | ||||||||
LastUpdateDate: | 05/20/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | MD24238 | OR | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RX0202X | MD24238 | OR | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
ID | Type | State | Issuer | Description | 286215 | 05 | OR |   | MEDICAID | 830008657 | 01 | OR | RAILROAD PROVIDER NUMBER | OTHER | 9940385 | 01 | OR | NAME VERIFICATION - OREGON DRIVERS LICENSE-CHERRY HAS NO LAST NAME | OTHER | 1407812365 | 01 | OR | GROUP NPI NUMBER | OTHER | CB3544 | 01 | OR | TRAV RR MED GROUP NUMBER | OTHER | 930635514 | 01 | OR | GROUP TAX ID FOR BILLING | OTHER | MD24238 | 01 | OR | MEDICAL LICENSE OREGON | OTHER | R0000WFBTV | 01 | OR | GROUP PIN NUMBER | OTHER |