Basic Information
| Provider Information | |||||||||
| NPI: | 1366485328 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKERSON | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 29TH AVE N | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153274304 | ||||||||
| FaxNumber: | 6153277940 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 29TH AVE N | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153274304 | ||||||||
| FaxNumber: | 6153277940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 11/06/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD28027 | TN | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | MD28027 | TN | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10070175 | 01 | TN | AMERIGROUP | OTHER | 3154927 | 01 | TN | BCBS | OTHER | 64006620 | 01 | KY | KY MEDICAID | OTHER | 050076661 | 01 | TN | RAILROAD MEDICARE | OTHER | 1629350 | 01 | TN | FIRST HEALTH | OTHER | 3800326 | 05 | TN | MEDICAID |