Provider Demographics
NPI:1073512059
Name:DICKERSON, MICHAEL M (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:M
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1602 GREENMONT HILLS DR
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-3292
Mailing Address - Country:US
Mailing Address - Phone:304-424-2228
Mailing Address - Fax:304-420-7128
Practice Address - Street 1:800 GARFIELD AVE
Practice Address - Street 2:HEALING CENTER AT CCMH
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-5340
Practice Address - Country:US
Practice Address - Phone:304-424-2228
Practice Address - Fax:304-420-7128
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001115207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89127TYMedicaid
NCD0709OtherMEDCOST #
NC127TYOtherBCBS OF NC GROUP #015CK
NC2281277CMedicare ID - Type UnspecifiedGROUP # 2336501
DI0845395Medicare PIN
NCD0709OtherMEDCOST #