Basic Information
| Provider Information | |||||||||
| NPI: | 1093719734 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKSON | ||||||||
| FirstName: | RALPH | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 70 ACADEMY ST | ||||||||
| Address2: | |||||||||
| City: | MC SHERRYSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173442116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176374188 | ||||||||
| FaxNumber: | 7176377803 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 ACADEMY ST | ||||||||
| Address2: | |||||||||
| City: | MC SHERRYSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173442116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176374188 | ||||||||
| FaxNumber: | 7176377803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 01/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD044609L | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1596587 | 05 | PA | MEDICAID | 582297 | 01 | PA | MEDICARE LEGACY PROVIDER | OTHER |