Provider Demographics
NPI:1851452411
Name:DICKENSON MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:DICKENSON MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RIMON
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-926-4601
Mailing Address - Street 1:PO BOX 2224
Mailing Address - Street 2:
Mailing Address - City:CLINTWOOD
Mailing Address - State:VA
Mailing Address - Zip Code:24228-2224
Mailing Address - Country:US
Mailing Address - Phone:276-926-4601
Mailing Address - Fax:276-926-4602
Practice Address - Street 1:5607 DICKENSON HIGHWAY
Practice Address - Street 2:
Practice Address - City:CLINTWOOD
Practice Address - State:VA
Practice Address - Zip Code:24228
Practice Address - Country:US
Practice Address - Phone:276-926-4601
Practice Address - Fax:276-926-4602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010264995Medicaid
VAF82939Medicare UPIN
VA010264995Medicaid
C09830Medicare PIN