Basic Information
| Provider Information | |||||||||
| NPI: | 1013936814 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DICK | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | PHILIP | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3702 NEW VISION DR BLDG B | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602666013 | ||||||||
| FaxNumber: | 2604585831 | ||||||||
| Practice Location | |||||||||
| Address1: | 3898 NEW VISION DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604255750 | ||||||||
| FaxNumber: | 2604255755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 05/23/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0208X | 01041905 | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases | 208000000X | 01041905 | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2024786 | 05 | OH | MEDICAID | 100460690 | 05 | IN | MEDICAID |