Provider Demographics
NPI:1689671273
Name:BARRETT PARKWAY FOOT AND LEG
Entity Type:Organization
Organization Name:BARRETT PARKWAY FOOT AND LEG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-422-0280
Mailing Address - Street 1:440 ERNEST W BARRETT PKWY NW
Mailing Address - Street 2:STE 62
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-4918
Mailing Address - Country:US
Mailing Address - Phone:770-042-2028
Mailing Address - Fax:770-426-5388
Practice Address - Street 1:440 ERNEST W BARRETT PKWY NW
Practice Address - Street 2:STE 62
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-4918
Practice Address - Country:US
Practice Address - Phone:770-042-2028
Practice Address - Fax:770-426-5388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-28
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA000961213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000954643CMedicaid
GA48SCCNKMedicare PIN
GAU88000Medicare UPIN
GA5045430001Medicare NSC