Basic Information
| Provider Information | |||||||||
| NPI: | 1215914239 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKINSON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2801 CHARLOTTE AVE | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372094035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152509200 | ||||||||
| FaxNumber: | 6152509251 | ||||||||
| Practice Location | |||||||||
| Address1: | 4601 CAROTHERS PKWY | ||||||||
| Address2: | STE 475 | ||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370675980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157901660 | ||||||||
| FaxNumber: | 6157903705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2005 | ||||||||
| LastUpdateDate: | 02/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | MD37792 | TN | Y | Allopathic & Osteopathic Physicians | Urology | 208800000X | A67587 | CA | N | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 3886483 | 05 | TN | MEDICAID | P00035782 | 01 | TN | RR MEDICARE | OTHER | 64069941 | 05 | KY | MEDICAID | 4067530 | 01 | TN | BLUE CROSS | OTHER |