Provider Demographics
NPI:1942489299
Name:JEFFREY W DICKERSON MD LLC
Entity Type:Organization
Organization Name:JEFFREY W DICKERSON MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-759-8000
Mailing Address - Street 1:991 MEDICAL PARK DRIVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056
Mailing Address - Country:US
Mailing Address - Phone:606-759-8000
Mailing Address - Fax:606-759-0461
Practice Address - Street 1:991 MEDICAL PARK DRIVE
Practice Address - Street 2:SUITE 202
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056
Practice Address - Country:US
Practice Address - Phone:606-759-8000
Practice Address - Fax:606-759-0461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP12034749OtherMULTIPLAN
KY1210239OtherCHA
KY000000322098OtherANTHEM
1346317575OtherINDIVIDUAL NPI
KYK25580OtherHUMANA
OH2473210Medicaid
KYP00206691OtherRR MEDICARE
KY64258809Medicaid
1346317575OtherINDIVIDUAL NPI
KY=========OtherUNITED HEALTHCARE
KY=========OtherAETNA