Provider Demographics
NPI:1770542797
Name:DICKINSON, CHRISTINE
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:DICKINSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 W 13 MILE RD
Mailing Address - Street 2:400-FSC/PCS
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 HARRINGTON ST
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2920
Practice Address - Country:US
Practice Address - Phone:734-677-7400
Practice Address - Fax:734-677-1603
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060673207U00000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3445124Medicaid
MICI8050OtherMEDICARE RR GROUP PIN
MIA37694Medicare UPIN
MI3445124Medicaid