Basic Information
| Provider Information | |||||||||
| NPI: | 1285625996 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SLOCUM DICKSON MEDICAL GROUP PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1729 BURRSTONE RD | ||||||||
| Address2: | |||||||||
| City: | NEW HARTFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134131001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157981700 | ||||||||
| FaxNumber: | 3157981707 | ||||||||
| Practice Location | |||||||||
| Address1: | 1729 BURRSTONE RD | ||||||||
| Address2: | |||||||||
| City: | NEW HARTFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134131001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157981700 | ||||||||
| FaxNumber: | 3157981707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 06/11/2021 | ||||||||
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| AuthorizedOfficialLastName: | EADLINE | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3157981700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | N | Laboratories | Clinical Medical Laboratory | 261Q00000X | 47440 | NY | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 02995013 | 05 | NY | MEDICAID |