MEDICARE: BREANA DICKSON MD,DO,

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	251E00000X	Home Health Agency	CNA2002094	IN

General Provider Information

NPI Number	:	1871170746
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BREANA DICKSON MD,DO,

Provider Business Mailing Address
First Line	:	2760 S EAST ST APT 103
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46225-2276
Country	:	US
Telephone Number	:	317-986-1260
Fax Number	:

Provider Business Practice Location Address
First Line	:	2760 S EAST ST APT 103
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46225-2276
Country	:	US
Telephone Number	:	317-986-1260
Fax Number	:

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

Provider Enumeration Date	:	03/26/2021
Last Update Date	:	03/26/2021

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