Healthcare Provider Details

I. General information

NPI: 1487692430
Provider Name (Legal Business Name): DEBORAH LEA FOWLER DIXON BROSS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEBORAH LEA FOWLER-DIXON MD

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 01/04/2025
Certification Date: 01/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 EDWARDSVILLE ROAD
TROY IL
62294
US

IV. Provider business mailing address

301 EDWARDSVILLE ROAD
TROY IL
62294
US

V. Phone/Fax

Practice location:
  • Phone: 618-667-7057
  • Fax: 618-667-8131
Mailing address:
  • Phone: 618-667-7057
  • Fax: 618-667-8131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036091572
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036901572
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: