Provider Demographics
NPI:1003904269
Name:DICKSON INC
Entity type:Organization
Organization Name:DICKSON INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:DICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-455-1464
Mailing Address - Street 1:PO BOX 110
Mailing Address - Street 2:
Mailing Address - City:SHILOH
Mailing Address - State:NJ
Mailing Address - Zip Code:08353-0110
Mailing Address - Country:US
Mailing Address - Phone:856-455-1464
Mailing Address - Fax:856-455-6381
Practice Address - Street 1:851 MAIN ST
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:NJ
Practice Address - Zip Code:08353-8505
Practice Address - Country:US
Practice Address - Phone:856-455-1464
Practice Address - Fax:856-455-6381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA53365207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2673304Medicaid
026492Medicare PIN