1376309815 NPI number — AMY DICKERSON CDMS

Table of content: AMY DICKERSON CDMS (NPI 1376309815)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376309815 NPI number — AMY DICKERSON CDMS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DICKERSON
Provider First Name:
AMY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CDMS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PALMER
Provider Other First Name:
AMY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1376309815
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5785 MATTOX CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORIENT
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43146-9321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-961-0413
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1590 N HIGH ST STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43201-2190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-688-2435
Provider Business Practice Location Address Fax Number:
614-292-0271
Provider Enumeration Date:
02/22/2024

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: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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