Basic Information
| Provider Information | |||||||||
| NPI: | 1902860216 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIXEY | ||||||||
| FirstName: | MIKE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4200 DAHLBERG DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525207870 | ||||||||
| FaxNumber: | 9525207580 | ||||||||
| Practice Location | |||||||||
| Address1: | 4010 W 65TH ST | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554351706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524567000 | ||||||||
| FaxNumber: | 9524567001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 11/09/2017 | ||||||||
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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 | 225100000X | 6119 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 610990000 | 05 | MN | MEDICAID | 176P7DI | 01 | MN | BC INDIV PROV ID | OTHER | 6405738 | 01 | FM | MEDICA INDIV PROV ID | OTHER |