1205975968 NPI number — BRIDGETON FOOT AND ANKLE LLC

Table of content: (NPI 1205975968)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205975968 NPI number — BRIDGETON FOOT AND ANKLE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIDGETON FOOT AND ANKLE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205975968
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12255 DE PAUL DR
Provider Second Line Business Mailing Address:
STE. 470
Provider Business Mailing Address City Name:
BRIDGETON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63044-2510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-739-8863
Provider Business Mailing Address Fax Number:
314-739-6448

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12255 DE PAUL DR
Provider Second Line Business Practice Location Address:
STE. 470
Provider Business Practice Location Address City Name:
BRIDGETON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63044-2510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-739-8863
Provider Business Practice Location Address Fax Number:
314-739-6448
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LOMBARDO
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
314-739-8863

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  000551 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2700030 . This is a "UHC" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 480034196 . This is a "RR MEDICARD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 32B00000X . This is a "MEDICAID DME" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 2784098 . This is a "UHC" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: P00419552 . This is a "RR MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 303231500 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300628401 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 310171750 . This is a "MEDICARE CPIN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 504595802 . This is a "MEDICAID GROUP" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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