Provider Demographics
NPI:1063487809
Name:DICKSON ORTHOPEDICS, P.A.
Entity Type:Organization
Organization Name:DICKSON ORTHOPEDICS, P.A.
Other - Org Name:JONESBORO ORTHOPEDICS AND SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KACEY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-932-1820
Mailing Address - Street 1:1010 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-3503
Mailing Address - Country:US
Mailing Address - Phone:870-932-1820
Mailing Address - Fax:870-972-6712
Practice Address - Street 1:1010 S MAIN ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3503
Practice Address - Country:US
Practice Address - Phone:870-932-1820
Practice Address - Fax:870-972-6712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC0874207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARCE8064OtherRAILROAD MEDICARE
AR232042748Medicaid
AR129705002Medicaid
AR129705002Medicaid
AR0473900001Medicare NSC