1699777854 NPI number — DR. GREGG ALAN DICKERSON M.D.

Table of content: DR. GREGG ALAN DICKERSON M.D. (NPI 1699777854)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699777854 NPI number — DR. GREGG ALAN DICKERSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DICKERSON
Provider First Name:
GREGG
Provider Middle Name:
ALAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1699777854
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10542 LIETER PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONE TREE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80124-9786
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-506-4753
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1514 E UNION ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38703-3248
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-332-6150
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/01/2005

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: 174400000X , with the licence number:  17812 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X , with the licence number: 47586 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10781438 . This is a "UNITEDHEALTHCARE CAQH" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 896610 . This is a "USA MANAGED CARE ORG" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 112927100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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