MEDICARE: DEBORAH LEA FOWLER DIXON BROSS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208M00000X	Hospitalist Physician	036091572	IL
2	207Q00000X	Family Medicine Physician	036901572	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487692430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBORAH LEA FOWLER DIXON BROSS MD

Provider Business Mailing Address
First Line	:	301 EDWARDSVILLE ROAD
Second Line	:
City	:	TROY
State	:	IL
Zip	:	62294
Country	:	US
Telephone Number	:	618-667-7057
Fax Number	:	618-667-8131

Provider Business Practice Location Address
First Line	:	301 EDWARDSVILLE ROAD
Second Line	:
City	:	TROY
State	:	IL
Zip	:	62294
Country	:	US
Telephone Number	:	618-667-7057
Fax Number	:	618-667-8131

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	01/04/2025

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