1053300400 NPI number — DR. GEORGE DIXON

Table of content: DR. GEORGE DIXON (NPI 1053300400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053300400 NPI number — DR. GEORGE DIXON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIXON
Provider First Name:
GEORGE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053300400
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 504552
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
61350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-234-1697
Provider Business Mailing Address Fax Number:
913-234-1116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4401 WORNALL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64111-3220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-932-2000
Provider Business Practice Location Address Fax Number:
913-234-1116
Provider Enumeration Date:
10/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  R3817 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 431560263 . This is a "TRICARE WEST" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00467070 . This is a "RR MEDICARE GROUP #DG5646" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 04777035 . This is a "BCBS KCMO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 100154530H , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 203727607 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 183261001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00852019 . This is a "RAILROAD MEDICARE GROUP CB9013" identifier . This identifiers is of the category "OTHER".




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