Provider Demographics
NPI:1235135682
Name:DIXON FAMILY PRACTICE AND INTERNAL MEDICINE, LLC
Entity Type:Organization
Organization Name:DIXON FAMILY PRACTICE AND INTERNAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLENE
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCMILLIAN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:573-759-3030
Mailing Address - Street 1:PO BOX 9900
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:MO
Mailing Address - Zip Code:65459-0940
Mailing Address - Country:US
Mailing Address - Phone:573-759-3030
Mailing Address - Fax:573-759-3131
Practice Address - Street 1:206 WEST 2ND STREET
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:MO
Practice Address - Zip Code:65459-0940
Practice Address - Country:US
Practice Address - Phone:573-759-3030
Practice Address - Fax:573-759-3131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6D44207Q00000X
MO263875261QR1300X
MO113217363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO508937000Medicaid
MO598937001Medicaid
MO508937000Medicaid
MOP51939Medicare UPIN
MO000013585Medicare PIN
MO598937001Medicaid
MO263875Medicare Oscar/Certification