Provider Demographics
NPI:1275882516
Name:JOHN H. DICKERSON DC PC
Entity Type:Organization
Organization Name:JOHN H. DICKERSON DC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:III
Authorized Official - Credentials:DC
Authorized Official - Phone:248-802-7928
Mailing Address - Street 1:830 E 4TH ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-2800
Mailing Address - Country:US
Mailing Address - Phone:248-584-4222
Mailing Address - Fax:
Practice Address - Street 1:830 E 4TH ST
Practice Address - Street 2:SUITE 5
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-2800
Practice Address - Country:US
Practice Address - Phone:248-584-4222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006942111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M22720Medicare UPIN