Provider Demographics
NPI:1639150055
Name:DICKEY, KEVIN WEBSTER (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:WEBSTER
Last Name:DICKEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751461
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1461
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:171 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-2016
Practice Address - Country:US
Practice Address - Phone:843-792-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC377602085R0204X, 2085R0202X
NC2015-011482085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001320978Medicaid
D45224Medicare UPIN
CT001320978Medicaid
CT300003785Medicare ID - Type Unspecified