Basic Information
| Provider Information | |||||||||
| NPI: | 1053300400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIXON | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 504552 | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 61350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9132341697 | ||||||||
| FaxNumber: | 9132341116 | ||||||||
| Practice Location | |||||||||
| Address1: | 4401 WORNALL RD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641113220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8169322000 | ||||||||
| FaxNumber: | 9132341116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 10/27/2010 | ||||||||
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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 | 2085R0202X | R3817 | MO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 431560263 | 01 | TRICARE WEST | OTHER | P00467070 | 01 | MO | RR MEDICARE GROUP #DG5646 | OTHER | 04777035 | 01 | MO | BCBS KCMO | OTHER | 100154530H | 05 | KS | MEDICAID | 203727607 | 05 | MO | MEDICAID | 183261001 | 05 | AR | MEDICAID | P00852019 | 01 | RAILROAD MEDICARE GROUP CB9013 | OTHER |