Provider Demographics
NPI:1023035748
Name:WILLIAM DICKIESON DPM PC
Entity Type:Organization
Organization Name:WILLIAM DICKIESON DPM PC
Other - Org Name:PREMIER FOOT & ANKLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:FAWAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-219-0323
Mailing Address - Street 1:1213 MASON ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2841
Mailing Address - Country:US
Mailing Address - Phone:313-561-2446
Mailing Address - Fax:313-561-7299
Practice Address - Street 1:1213 MASON ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2841
Practice Address - Country:US
Practice Address - Phone:313-561-2446
Practice Address - Fax:313-561-7299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
213E00000X
MI5901001040261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatricGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2120106Medicaid
MI0P34100Medicare PIN
MI5130720001Medicare NSC
MI2120106Medicaid