Provider Demographics
NPI:1720086242
Name:DICKSON, STEPHEN L JR (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:L
Last Name:DICKSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 NAPIER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2112
Mailing Address - Country:US
Mailing Address - Phone:269-983-8172
Mailing Address - Fax:699-854-5352
Practice Address - Street 1:2500 NILES RD STE 6
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-3268
Practice Address - Country:US
Practice Address - Phone:269-408-1660
Practice Address - Fax:269-408-1665
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY43991208G00000X
IN01058168A208G00000X
MI4301114501208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50031859OtherPASSPORT- CTS
KY000057094VOtherHUMANA- CTS
KY64076821Medicaid
IN200455130AMedicaid
KY000000701004OtherANTHEM- CTS
IN200455130Medicaid
KY4001605OtherCIGNA- CTS
KY000000701004OtherANTHEM- CTS
KY000057094VOtherHUMANA- CTS
IN200455130Medicaid
H48208Medicare UPIN