Provider Demographics
NPI:1750785150
Name:JEROME ANTHONY DIXON D O P S C
Entity type:Organization
Organization Name:JEROME ANTHONY DIXON D O P S C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:MONHOLLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-525-1459
Mailing Address - Street 1:150 W BEAR TRACK RD
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-8709
Mailing Address - Country:US
Mailing Address - Phone:270-465-8133
Mailing Address - Fax:270-789-1543
Practice Address - Street 1:150 W BEAR TRACK RD
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-8709
Practice Address - Country:US
Practice Address - Phone:270-465-8133
Practice Address - Fax:270-789-1543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-14
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1071186363L00000X
KY3007692363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK079192Medicare PIN
KYK124130Medicare PIN