Healthcare Provider Details

I. General information

NPI: 1154857209
Provider Name (Legal Business Name): MADELINE ANN DICKS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 W THOMAS RD STE 114
PHOENIX AZ
85013-4420
US

IV. Provider business mailing address

240 W THOMAS RD # 301
PHOENIX AZ
85013-4407
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-6304
  • Fax: 602-406-6302
Mailing address:
  • Phone: 602-406-7765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number95301
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number19484
License Number StateND
# 4
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number010088
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: