Provider Demographics
NPI:1295808582
Name:DICKEN PA
Entity type:Organization
Organization Name:DICKEN PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:DICKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-681-3300
Mailing Address - Street 1:1720 HIGHWAY 59 SOUTHEAST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-0505
Mailing Address - Country:US
Mailing Address - Phone:218-681-3300
Mailing Address - Fax:218-681-6733
Practice Address - Street 1:1720 HIGHWAY 59 SOUTHEAST
Practice Address - Street 2:SUITE 1
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-0505
Practice Address - Country:US
Practice Address - Phone:218-681-3300
Practice Address - Fax:218-681-6733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
880931027628OtherPREFERRED ONE
17986OtherHEALTH PARTNERS
0824440OtherMEDICA
17986OtherHEALTH PARTNERS