Healthcare Provider Details

I. General information

NPI: 1376514521
Provider Name (Legal Business Name): EDWARD ERNEST DICKERSON, IV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2053 VALLEYGATE DR STE 102
FAYETTEVILLE NC
28304-3983
US

IV. Provider business mailing address

PO BOX 2814
BRYSON CITY NC
28713-2814
US

V. Phone/Fax

Practice location:
  • Phone: 910-323-9222
  • Fax:
Mailing address:
  • Phone: 910-239-7600
  • Fax: 828-538-4441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number9400044
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number94-00044
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number9400044
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: