Basic Information
| Provider Information | |||||||||
| NPI: | 1720086242 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DICKSON | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 NAPIER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490852112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699838172 | ||||||||
| FaxNumber: | 6998545352 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 NILES RD STE 6 | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490853268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694081660 | ||||||||
| FaxNumber: | 2694081665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 06/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 43991 | KY | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 01058168A | IN | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 4301114501 | MI | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 50031859 | 01 | KY | PASSPORT- CTS | OTHER | 000057094V | 01 | KY | HUMANA- CTS | OTHER | 64076821 | 05 | KY | MEDICAID | 200455130A | 05 | IN | MEDICAID | 000000701004 | 01 | KY | ANTHEM- CTS | OTHER | 200455130 | 05 | IN | MEDICAID | 4001605 | 01 | KY | CIGNA- CTS | OTHER |