Provider Demographics
NPI:1336643170
Name:DICKSON, MERCY
Entity Type:Individual
Prefix:
First Name:MERCY
Middle Name:
Last Name:DICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:376 W 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1280
Mailing Address - Country:US
Mailing Address - Phone:614-293-3570
Mailing Address - Fax:
Practice Address - Street 1:5325 FARAON ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3488
Practice Address - Country:US
Practice Address - Phone:816-271-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2021028957207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program