1912015108 NPI number — DICKSON MEDICAL ASSOCIATES, PC

Table of content: (NPI 1912015108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912015108 NPI number — DICKSON MEDICAL ASSOCIATES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DICKSON MEDICAL ASSOCIATES, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1912015108
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
127 CRESTVIEW PARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DICKSON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37055-2855
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-446-5121
Provider Business Mailing Address Fax Number:
615-446-1357

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5194 HIGHWAY 100
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
LYLES
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37098-2821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-670-1102
Provider Business Practice Location Address Fax Number:
615-446-1357
Provider Enumeration Date:
08/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LIGHTHILL
Authorized Official First Name:
CINDY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
615-441-4477

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3721355 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3158185 . This is a "BCBS TN GROUP PIN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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