Basic Information
Provider Information | |||||||||
NPI: | 1699777854 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DICKERSON | ||||||||
FirstName: | GREGG | ||||||||
MiddleName: | ALAN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10542 LIETER PL | ||||||||
Address2: |   | ||||||||
City: | LONE TREE | ||||||||
State: | CO | ||||||||
PostalCode: | 801249786 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3035064753 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1514 E UNION ST | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | MS | ||||||||
PostalCode: | 387033248 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6623326150 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2005 | ||||||||
LastUpdateDate: | 11/30/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 17812 | MS | N |   | Other Service Providers | Specialist |   | 2085R0001X | 47586 | CO | Y |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
ID | Type | State | Issuer | Description | 10781438 | 01 | MS | UNITEDHEALTHCARE CAQH | OTHER | 896610 | 01 | MN | USA MANAGED CARE ORG | OTHER |