Provider Demographics
NPI:1699958421
Name:RIVERDALE FOOT, ANKLE AND LEG CLINIC
Entity type:Organization
Organization Name:RIVERDALE FOOT, ANKLE AND LEG CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-997-3668
Mailing Address - Street 1:6567 PROFESSIONAL PL
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2519
Mailing Address - Country:US
Mailing Address - Phone:770-997-3668
Mailing Address - Fax:770-997-3470
Practice Address - Street 1:6567 PROFESSIONAL PL
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2519
Practice Address - Country:US
Practice Address - Phone:770-997-3668
Practice Address - Fax:770-997-3470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-15
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000890213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA7302184OtherAETNA
GA52811908OtherBLUE CROSS BLUE SHIELD
GA00869679EMedicaid
GA52811908OtherBLUE CROSS BLUE SHIELD
GA5533180001Medicare NSC
GA00869679EMedicaid