Provider Demographics
NPI:1508932955
Name:JEROME ANTHONY DIXON D O P S C
Entity Type:Organization
Organization Name:JEROME ANTHONY DIXON D O P S C
Other - Org Name:JEROME A. DIXON, D.O., P.S.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:A
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:270-465-8133
Mailing Address - Street 1:150 W BEAR TRACK RD
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-8709
Mailing Address - Country:US
Mailing Address - Phone:270-465-8133
Mailing Address - Fax:270-789-1543
Practice Address - Street 1:150 W BEAR TRACK RD
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-8709
Practice Address - Country:US
Practice Address - Phone:270-465-8133
Practice Address - Fax:270-789-1543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02320207Q00000X
KY4091P363LF0000X
KY3007692363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64023203Medicaid
KYE92006Medicare UPIN
KY64023203Medicaid