MEDICARE: DR. GREGG ALAN DICKERSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	17812	MS
2	2085R0001X	Radiation Oncology Physician	47586	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10781438	OTHER	MS	UNITEDHEALTHCARE CAQH
2	896610	OTHER	MN	USA MANAGED CARE ORG
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699777854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGG ALAN DICKERSON M.D.

Provider Business Mailing Address
First Line	:	10542 LIETER PL
Second Line	:
City	:	LONE TREE
State	:	CO
Zip	:	80124-9786
Country	:	US
Telephone Number	:	303-506-4753
Fax Number	:

Provider Business Practice Location Address
First Line	:	1514 E UNION ST
Second Line	:
City	:	GREENVILLE
State	:	MS
Zip	:	38703-3248
Country	:	US
Telephone Number	:	662-332-6150
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	11/30/2016

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