Provider Demographics
NPI:1720032766
Name:WOODRIDGE, CHARLES ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ANTHONY
Last Name:WOODRIDGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7319 S CHAMPLAIN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-1828
Mailing Address - Country:US
Mailing Address - Phone:773-490-2043
Mailing Address - Fax:
Practice Address - Street 1:7319 S CHAMPLAIN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-1828
Practice Address - Country:US
Practice Address - Phone:773-490-2043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086962207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036086962/ILMedicaid
IL571040Medicare UPIN
IL208914Medicare ID - Type UnspecifiedIDTF LOCALITY 15
IL208916Medicare ID - Type UnspecifiedIDTF LOCALITY 99
IL660800Medicare UPIN
IL551230Medicare UPIN
IL208915Medicare ID - Type UnspecifiedIDTF LOCALITY 16
IL036086962/ILMedicaid