1528021706 NPI number — DR. MATTHEW JORDAN DICKSON M.D.

Table of content: DR. MATTHEW JORDAN DICKSON M.D. (NPI 1528021706)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528021706 NPI number — DR. MATTHEW JORDAN DICKSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DICKSON
Provider First Name:
MATTHEW
Provider Middle Name:
JORDAN
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:
1528021706
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 PARK STREET
Provider Second Line Business Mailing Address:
GLENS FALLS HOSPITAL - CREDENTIALING
Provider Business Mailing Address City Name:
GLENS FALLS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12801-4413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-926-5924
Provider Business Mailing Address Fax Number:
518-926-6983

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14 HUDSON AVENUE
Provider Second Line Business Practice Location Address:
ADIRONDACK ENT
Provider Business Practice Location Address City Name:
GLENS FALLS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12801-4363
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-926-1380
Provider Business Practice Location Address Fax Number:
518-926-1385
Provider Enumeration Date:
04/10/2006

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: 207YX0905X , with the licence number:  244280 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207YS0123X , with the licence number: 57061 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 02897047 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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