Basic Information
| Provider Information | |||||||||
| NPI: | 1538691696 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKENS | ||||||||
| FirstName: | HALLUM | ||||||||
| MiddleName: | KIRKWOOOD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | IV | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7974 UW HEALTH CT | ||||||||
| Address2: | |||||||||
| City: | MIDDLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535625531 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 N NINE MOUND RD | ||||||||
| Address2: | |||||||||
| City: | VERONA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535931032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088459531 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2017 | ||||||||
| LastUpdateDate: | 10/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2018-02244 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 77275 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.