Basic Information
| Provider Information | |||||||||
| NPI: | 1245226083 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DYKE | ||||||||
| FirstName: | CORNELIUS | ||||||||
| MiddleName: | MCKOWN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 BROADWAY N | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581023641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012342331 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2555 COURT DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280542134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046717670 | ||||||||
| FaxNumber: | 7046717672 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 09/26/2013 | ||||||||
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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 | 208G00000X | 9800242 | NC | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 11686 | ND | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 891127W | 05 | NC | MEDICAID | N00243 | 05 | SC | MEDICAID | P00223121 | 01 | NC | RAILROAD MEDICARE | OTHER |