Provider Demographics
NPI:1225248396
Name:RIDGELAND FOOT AND ANKLE CENTER LTD
Entity Type:Organization
Organization Name:RIDGELAND FOOT AND ANKLE CENTER LTD
Other - Org Name:CAMILLERI MEDICAL CENTER LTD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMILLERI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:708-788-5239
Mailing Address - Street 1:6845 STANLEY AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3041
Mailing Address - Country:US
Mailing Address - Phone:708-788-5239
Mailing Address - Fax:708-788-3618
Practice Address - Street 1:6845 STANLEY AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3041
Practice Address - Country:US
Practice Address - Phone:708-788-5239
Practice Address - Fax:708-788-3618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004695213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL60001136OtherBLUE CROSS BLUE SHIELD
IL543690Medicare PIN
IL60001136OtherBLUE CROSS BLUE SHIELD
ILU53851Medicare UPIN