Basic Information
| Provider Information | |||||||||
| NPI: | 1528021706 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DICKSON | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | JORDAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PARK STREET | ||||||||
| Address2: | GLENS FALLS HOSPITAL - CREDENTIALING | ||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128014413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189265924 | ||||||||
| FaxNumber: | 5189266983 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 BROAD STREET PLZ | ||||||||
| Address2: | ADIRONDACK ENT | ||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128014363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189261380 | ||||||||
| FaxNumber: | 5189261385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YS0123X | 57061 | GA | N | Allopathic & Osteopathic Physicians | Otolaryngology | Facial Plastic Surgery | 207YX0905X | 244280 | NY | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 02897047 | 05 | NY | MEDICAID |