Individual
TIMOTHY DALE DICKINSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1 MEDICAL VILLAGE DR, EDGEWOOD, KY 41017-3403
(859) 341-7246
(859) 341-7867
Mailing address
20 MEDICAL VILLAGE DR, SUITE 258, EDGEWOOD, KY 41017-5401
(859) 341-7246
(859) 341-7867
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
38335
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000311761
ANTHEM BLUE SHIELD
—
05
—
0310694
—
OH
01
—
10902391
CAQH
—
05
—
200282600
—
IN
01
—
611077369
TAX ID
—
05
—
64074628
—
KY
01
—
7580059
AETNA
—
Enumeration date
11/22/2005
Last updated
10/31/2013
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