Provider Demographics
NPI:1790941011
Name:DICKERSON, ELIZABETH ANNE (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 PACES FERRY RD SE
Mailing Address - Street 2:BUILDING 1, SUITE 1100
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-4053
Mailing Address - Country:US
Mailing Address - Phone:770-801-2526
Mailing Address - Fax:
Practice Address - Street 1:2727 PACES FERRY RD SE
Practice Address - Street 2:BUILDING 1, SUITE 1100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-4053
Practice Address - Country:US
Practice Address - Phone:770-801-2526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036136207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF98280Medicare UPIN