Healthcare Provider Details

I. General information

NPI: 1548581226
Provider Name (Legal Business Name): DAVID MICHAEL DICKERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2010
Last Update Date: 10/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE. DEPARTMENT OF ANESTHESIA
EVANSTON IL
60201
US

IV. Provider business mailing address

2650 RIDGE AVE. DEPARTMENT OF ANESTHESIA
EVANSTON IL
60201-1718
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2287
  • Fax: 847-570-2921
Mailing address:
  • Phone: 847-570-2287
  • Fax: 847-570-2921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number125054403
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number036132595
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number036132595
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: