Provider Demographics
NPI:1124085147
Name:DICKSON, JAMES BRICE (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:BRICE
Last Name:DICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 TAYLOR ST
Mailing Address - Street 2:SUITE 4G
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2923
Mailing Address - Country:US
Mailing Address - Phone:803-799-9919
Mailing Address - Fax:803-799-0788
Practice Address - Street 1:1333 TAYLOR ST
Practice Address - Street 2:SUITE 4G
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2923
Practice Address - Country:US
Practice Address - Phone:803-799-9919
Practice Address - Fax:803-799-0788
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13271174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC132715Medicaid
SC132715Medicaid