Basic Information
| Provider Information | |||||||||
| NPI: | 1952307498 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUBBARD | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | LEROY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 875 OAK ST SE | ||||||||
| Address2: | STE 5060 | ||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973013987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033991386 | ||||||||
| FaxNumber: | 5033991182 | ||||||||
| Practice Location | |||||||||
| Address1: | 875 OAK ST SE | ||||||||
| Address2: | STE 5060 | ||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973013987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033991386 | ||||||||
| FaxNumber: | 5033991182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2005 | ||||||||
| LastUpdateDate: | 04/10/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | MD11848 | OR | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 118968 | 05 | OR | MEDICAID |