Healthcare Provider Details

I. General information

NPI: 1174797427
Provider Name (Legal Business Name): RACHEL ANNE DICKERSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2008
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date: 01/06/2020
Reactivation Date: 02/03/2020

III. Provider practice location address

15421 CLAYTON RD STE 202
BALLWIN MO
63011-3161
US

IV. Provider business mailing address

15421 CLAYTON RD STE 202
BALLWIN MO
63011-3161
US

V. Phone/Fax

Practice location:
  • Phone: 314-639-9060
  • Fax: 314-689-1871
Mailing address:
  • Phone: 314-639-9060
  • Fax: 314-689-1871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2012012812
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2012012812
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: