Provider Demographics
NPI:1174797427
Name:DICKERSON, RACHEL ANNE (MD)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:ANNE
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 PROSPECT AVE STE 202A
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-6067
Mailing Address - Country:US
Mailing Address - Phone:314-394-2973
Mailing Address - Fax:785-414-5373
Practice Address - Street 1:111 PROSPECT AVE STE 202A
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-6067
Practice Address - Country:US
Practice Address - Phone:314-394-2973
Practice Address - Fax:785-414-5373
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-17
Last Update Date:2024-11-20
Deactivation Date:2020-01-06
Deactivation Code:
Reactivation Date:2020-02-03
Provider Licenses
StateLicense IDTaxonomies
MO2012012812208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1174797427Medicaid
MOMA5871001Medicare PIN