Provider Demographics
NPI:1033440342
Name:MALCOLM J. DICKERSON, M.D., P.C.
Entity Type:Organization
Organization Name:MALCOLM J. DICKERSON, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:JO
Authorized Official - Last Name:ROUTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-392-9200
Mailing Address - Street 1:411 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ELDON
Mailing Address - State:MO
Mailing Address - Zip Code:65026-1919
Mailing Address - Country:US
Mailing Address - Phone:573-392-9200
Mailing Address - Fax:573-392-4626
Practice Address - Street 1:411 W 4TH ST
Practice Address - Street 2:
Practice Address - City:ELDON
Practice Address - State:MO
Practice Address - Zip Code:65026-1919
Practice Address - Country:US
Practice Address - Phone:573-392-9200
Practice Address - Fax:573-392-4626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5N38207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty