=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730367970
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDGAR G. DICKEY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2008
-----------------------------------------------------
Last Update Date | 11/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 W MAIN ST
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62837-2502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-842-2655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 W MAIN ST
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62837-2502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-842-2655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OD
-----------------------------------------------------
Name | EDGAR GREGG DICKEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 618-842-2655
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------