Provider Demographics
NPI:1538163381
Name:DICKSON, ERNEST (PT)
Entity type:Individual
Prefix:
First Name:ERNEST
Middle Name:
Last Name:DICKSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2066
Mailing Address - Fax:423-857-2070
Practice Address - Street 1:105 W STONE DR
Practice Address - Street 2:SUITE 1D
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3256
Practice Address - Country:US
Practice Address - Phone:423-578-1560
Practice Address - Fax:423-392-7055
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1540225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3658839Medicaid
0281780001Medicare PIN
0281780003Medicare PIN
TN3658839Medicare ID - Type Unspecified
TNP00132090Medicare PIN
TNCC0450Medicare PIN
TN3658839Medicaid