Provider Demographics
NPI:1689952061
Name:ROBERT H DICKASON D O P C
Entity Type:Organization
Organization Name:ROBERT H DICKASON D O P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:H
Authorized Official - Last Name:DICKASON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:734-676-5353
Mailing Address - Street 1:5400 FORT ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-4632
Mailing Address - Country:US
Mailing Address - Phone:734-676-5353
Mailing Address - Fax:734-676-5524
Practice Address - Street 1:5400 FORT ST
Practice Address - Street 2:SUITE 210
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-4632
Practice Address - Country:US
Practice Address - Phone:734-676-5353
Practice Address - Fax:734-676-5524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-02
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006962208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1710979869Medicaid
MIMI4934Medicare PIN
MIB43680Medicare UPIN