Provider Demographics
NPI:1043394471
Name:J KEVIN DICKENSON MD
Entity Type:Organization
Organization Name:J KEVIN DICKENSON MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:DICKENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-894-8211
Mailing Address - Street 1:PO BOX 207
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25802-0207
Mailing Address - Country:US
Mailing Address - Phone:304-894-8211
Mailing Address - Fax:304-894-8213
Practice Address - Street 1:2401 S KANAWHA ST
Practice Address - Street 2:SUITE 104
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-6967
Practice Address - Country:US
Practice Address - Phone:304-894-8211
Practice Address - Fax:304-894-8213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19735208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001759805OtherBC BS GROUP ID
WV001759805OtherBC BS GROUP ID