1942489299 NPI number — JEFFREY W DICKERSON MD LLC

Table of content: (NPI 1942489299)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942489299 NPI number — JEFFREY W DICKERSON MD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFREY W DICKERSON MD LLC
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:
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:
1942489299
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
991 MEDICAL PARK DRIVE
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
MAYSVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-759-8000
Provider Business Mailing Address Fax Number:
606-759-0461

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
991 MEDICAL PARK DRIVE
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
MAYSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-759-8000
Provider Business Practice Location Address Fax Number:
606-759-0461
Provider Enumeration Date:
11/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DICKERSON
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
606-759-8000

Provider Taxonomy Codes

  • Taxonomy code: 207RS0012X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P12034749 . This is a "MULTIPLAN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1210239 . This is a "CHA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000322098 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1346317575 . This is a "INDIVIDUAL NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: K25580 . This is a "HUMANA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 2473210 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00206691 . This is a "RR MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64258809 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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